Prepared by the Center forInfectious Disease Research andPolicy (CIDRAP) at the Universityof Minnesota

Sponsored by the Associationof State and Territorial HealthOfficials (ASTHO)

H1N1 &Higher EdLESSONS LEARNED

Pandemic Influenza

Tools,Tips, and

Takeaways from the

Big 10+2 Universities

November 2010

H1N1 & Higher Ed: Lessons LearnedPandemic Influenza Tools, Tips, and Takeaways from the Big 10+2 Universities

The Center for Infectious Disease Research and Policy (CIDRAP)CIDRAP, founded in 2001, is a global leader in addressing public health preparedness and emerginginfectious disease response. Part of the Academic Health Center at the University of Minnesota, thecenter reduces illness and death from infectious diseases by effecting change through public policyrefinement, fostering the adoption of science-based best practices in public health among professionalsand the public, and conducting original interdisciplinary research.

This publication is designed to provide accurate and authoritative information with regard to the subject mattercovered. It is published with the understanding that the publisher is not engaged in rendering legal, medical, orother professional services. If legal advice or other expert assistance is required, the services of a competentprofessional should be sought. All URLs were verified at the time of publication.

The Center for Infectious Disease Research and Policy (CIDRAP) authorizes the making and distribution of copies orexcerpts (in a manner that does not distort the meaning of the original) of this information for non-commercial,educational purposes within organizations. The following credit line must appear: “Reprinted with permission ofthe Center for Infectious Disease Research and Policy. Copyright © 2010. Regents of the University of Minnesota.”No other republication or external use is allowed without the permission of CIDRAP. For information or inquiries,please e-mail CIDRAP@umn.edu with the words “Big 10+2” in the subject line.

Copyright © 2010 Regents of the University of Minnesota. All rights reserved. This paper was made possible withCenters for Disease Control and Prevention (CDC) funding provided by the Association of State and Territorial HealthOfficials (ASTHO), prepared by Kathleen Kimball-Baker, Jill DeBoer, and Amy Becker LaFrance, and designed by NancyWester Design. A copy of this report is available at: www.PublicHealthPractices.org

Photo credits. Cover images, from left to right: © iStockphoto.com/Joshua Hodge Photography, © iStockphoto.com/Forest Woodward,© iStockphoto.com/Ben Blankenburg, © Centers for Disease Control and Prevention; Background photo: © iStockphoto.com/Sander Kamp

olleges and universities played key roles in the nation’sresponse to the 2009 H1N1 influenza pandemic. Thegoal of The Big 10 + 2 Universities H1N1 Lessons

Learned Project has been to find and tell the success storiesfrom this experience and to raise the many issues yet to beresolved before the next influenza pandemic. Information wascollected through (1) key informant interviews conductedbetween March and July 2010, (2) an online conference hostedMay 18, 2010, for the Big 10+2 universities, their respective statehealth departments, and Centers for Disease Control andPrevention (CDC) partners, and (3) follow-up interviews.

University of Minnesota coordination and staffing support forthe project was provided by the Center for Infectious DiseaseResearch and Policy (CIDRAP), Academic Health Center,Boynton Health Service, and School of Public Health, withCDC funding provided by the Association of State andTerritorial Health Officials (ASTHO). In addition to this report,CIDRAP has (1) posted the webinar and presentation slidesfrom the May 18 event and (2) published Promising Practicesfor higher education at www.PublicHealthPractices.org.

H1N1 & Higher Ed: Lessons Learned | PARTNERS 1

PARTNERS

The Big 10+2 UniversitiesH1N1 Lessons Learned Project

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University of Chicago

University of Illinois

University of Michigan

The Ohio State University

Pennsylvania State University

Purdue University

University of Wisconsin-Madison

Michigan State University

Northwestern UniversityUniversity of Iowa

Indiana University

University of Minnesota

2 H1N1 & Higher Ed: Lessons Learned

Executive Summary 5

Introduction 7

Chapter 1 Incident Management 13Planning paid off

Chapter 2 Residence Halls 17Successful housing response depended on many campus partners

Chapter 3 Health Services 23An all-hands-on-deck approach was needed, as was the tenet ‘divide and conquer’

Chapter 4 Communications 29One voice, one message mattered most

Chapter 5 Vaccine Distribution 33Coping with uncertainty was key to success

Chapter 6 Teaching 39Supportive leadership made possible short-term solutions

Chapter 7 Human Resources 43Relaxing policies didn’t require revoking them

Chapter 8 Student Engagement 47Students were ‘a tremendous asset’

Chapter 9 Collaborations With Public Health 53Established partnerships enhanced response

Conclusion 57

Acknowledgments 60

H1N1 & Higher Ed: Lessons Learned | CONTENTS 3

Table of Contents

4 H1N1 & Higher Ed: Lessons Learned

he 12 universities that are featured inthis report spent more than 3 yearspreparing for an influenza pandemicof dire consequences. The one thatemerged in late April 2009 differed inmagnitude from the one theyexpected—but it left no aspect ofuniversity life untouched. Universitieshoused, fed, educated, and cared for

one of the populations most vulnerable during the 2009H1N1: young adults. The stakes were high, and thepreparedness work paid off. But it was the process of planning,more so than the actual plans, that produced what Big 10+2found most valuable—savvy teams that could pivot andrespond appropriately to a pandemic full of surprises.

This report represents the capstone of the Big 10+2Universities H1N1 Lessons Learned Project. The projectsought to identify and document the most essential lessonslearned from (1) planning for a hypothetical influenzapandemic and (2) responding to a real one, the 2009 H1N1influenza pandemic. The report also tells a compelling story ofhow 12 complex organizations—communities that functionlike cities and serve tens of thousands of people—workedtheir way from one side of the pandemic to the other.

Information gathered through key informant interviews andan online conference emphasized nine topics: (1) incidentmanagement, (2) residence halls, (3) university healthservices, (4) communication, (5) vaccine distribution, (6)teaching, (7) human resources, (8) student engagement, and(9) collaborations. This report illustrates key takeaways inthese areas through sample practices, direct quotes, tips, andbrief stories from the field.

The project underscored four overarching lessons that can betranslated into the following actions for pandemic planningand, likely, for other public health challenges:

1. Build and sustain partnerships. Response to H1N1required strong internal and external collaborations that werebuilt well before the pandemic and nurtured long-term.Joining forces with local public health authorities, for

example, gave universities access to information they neededto make critical decisions, while the combined efforts ofcampus health and residential life services ensured studentshad coordinated care. See chapters on incident management,residence halls, health services, communication, vaccinedistribution, and collaborations.

2. Cast a wide net for resources. Big 10+2 universitiesfound they could scale up their response by thinkingcreatively. Students turned out to be one of the universities’most important assets. Technology intended for other useswas adapted to streamline activities such as scheduling massvaccine clinics, monitoring sick patients, and pursuinginfection control strategies. See chapters on vaccinedistribution, health services, and student engagement.

3. Build flexibility into response plans. Universitiesdiscovered quickly that written plans didn’t always apply tothe threat at hand. They used the relative quiet of thesummer months to retool and shelved plans based on certaintriggers that didn’t jibe with H1N1 realities in favor of morerelevant logic models. They also sought ways to encourage illstudents who could not go home to self-isolate in residencehalls and apartments. See chapters on incident management,residence halls, and health services.

4. Tackle remaining challenges now. The H1N1 pandemicleft important issues unresolved, either owing to the natureof this particular pandemic or the fact that the plans were notfully fleshed out before H1N1 emerged. Such issues includehow to ensure educational continuity through distanceteaching, how to equitably adjust sick leave practices so thatemployees can afford to stay home when sick, and how tobuild faculty willingness to suspend doctor’s notes to excusepandemic flu–related absences. These are complicated issueswith no easy answers, but, if left unresolved, they’re likely toconfound response to a pandemic that causes more severe or widespread illness, results in more deaths, or lasts longer.See chapters on teaching and human resources.

Although the content was drawn from 12 large universities,many of the lessons and practices can inform the preparednessefforts of smaller institutions of higher education as well.

H1N1 & Higher Ed: Lessons Learned | EXECUTIVE SUMMARY 5

Executive SummaryAlthough the 2009 H1N1 influenza pandemic is often described as ‘mild,’ sucha characterization glosses over its considerable impact on college campuses.

6 H1N1 & Higher Ed: Lessons Learned

emarkably, the story of how collegesand universities coped with, endured,and were changed by the firstinfluenza pandemic of the 21stcentury has largely gone untold. Themillions of young adults served bycolleges and universities were amongthe groups most at risk for severeillness during the 2009 H1N1

influenza pandemic. Few other institutions were as likely tohouse, feed, teach, and care for such large clusters of peoplevulnerable to the novel H1N1 virus. So it follows that collegesand universities experienced the pandemic threat in anextraordinary way.

Nearly 80,000 college students were diagnosed with a flu-likeillness between Aug 22, 2009, and Apr 30, 2010, according tothe American College Health Association, which collecteddata from 165 colleges anduniversities during the H1N1pandemic. (Public health officialsbegan to assume such illness indicatedH1N1 infection after laboratory testingshowed that the pandemic strain wasresponsible for almost all cases ofinfluenza during that period.) No oneknows how many additional studentsbecame sick but never received adiagnosis. The number of staff, faculty,and administrators who became illalso is unknown. But it’s safe toassume that surveillance dataunderestimates the full extent ofH1N1 infection on college and university campuses.

No part of higher education escaped the tumult of the 2009H1N1 influenza pandemic. Nearly every aspect of collegeoperations—from athletics to communications to facilities andsecurity—had to break from business as usual to meet thechallenges.

What’s more, universities could not respond in a vacuum—nor did they try. Organized like cities (complete withemergency, security, and health services; utilities and

infrastructure; housing and businesses that serve residents;and a hierarchy of governance), Big 10+2 universities are, infact, self-contained communities. But they’re also locatedwithin the jurisdictions of cities or counties, which have theirown emergency response plans and responsibilities.

For several years leading up to the H1N1 pandemic, many Big10+2 universities and local public agencies built and testedplans. But it was the process, more so than the plansthemselves, that yielded what was most needed to respond tothe H1N1 pandemic: strong collaborative teams able toproblem-solve and pivot when plans didn’t match reality.

This document represents a collaboration among the Big 10+2institutions to document the strategies, practices, and tacticsfound to be most useful in addressing the 2009 H1N1influenza pandemic. It is funded by the Association of Stateand Territorial Health Officials (ASTHO). The many examples

and descriptions here draw uponmyriad experiences of students, faculty,administrators, care providers,planners, and members of partneringlocal public health and emergencyresponse agencies.

This information is meant to illustratea range of activities used to addresscommon challenges in highereducation. Inclusion here does notimply that a practice reported to haveworked well on one campus isnecessarily the best approach foranother. If anything, the Big 10+2

experience demonstrated that a one-size-fits-all approach doesnot exist. Influenza viruses—and pandemics—are notoriouslyunpredictable. Documenting what strategies worked well,what didn’t, what lessons were learned, and what challengesremain helps move pandemic readiness past theory andbuilds a knowledge base for the future.

The project included:

• Key informant interviews with representatives from eachuniversity to identify key themes and practices

H1N1 & Higher Ed: Lessons Learned | INTRODUCTION 7

IntroductionNo part of higher education escaped the tumult of the 2009 H1N1 influenzapandemic. Nearly every function had to break from business as usual.

It was the process, more sothan the plans themselves,that yielded what was mostneeded to respond to theH1N1 pandemic: strong collaborative teams.

TIP FROM THE FIELD

The 2009 H1N1 influenza pan-demic and where it emerged

caught people off guard, includ-ing people at colleges and uni-versities. Late in April 2009,concerns grew as news accountsbegan to flow out of Mexico ofadults with severe respiratoryproblems. Mexico was groundzero for the pandemic and aplace where many Big 10+2 stu-dents had recently visited, were

studying, or were preparing to visitfor special programs.

Among the first confirmed casesseen at universities were studentswho had traveled to Mexico duringspring break. Sporadic cases of2009 H1N1 pandemic infection ap-peared on campuses throughoutthe spring and summer. By fall, thelargest wave of H1N1-related illnessbegan to build as students returned

to campus, eventually peakingaround the end of October and be-ginning of November, then tailingoff by January 2010.

But the story actually begins before

the pandemic did.

The planning yearsFor years before the novel H1N1virus appeared, eyes had been onAsia and Africa, where the deadly

The Story That Flew Under the RadarThe story of how higher education pulled through the first influenza pandemic ofthe 21st century is a compelling one, filled with innovation and the dedication of awide variety of professionals.

8 INTRODUCTION | H1N1 & Higher Ed: Lessons Learned

• An online conference that provided snapshots ofpromising practices, highlights of lessons learned, and anopportunity to interact with staff from the US Centers forDisease Control and Prevention (CDC) and is archived forpublic use

• A collection of Promising Practices for HigherEducation, hosted by the University of Minnesota Centerfor Infectious Disease Research and Policy (CIDRAP) andASTHO at www.PublicHealthPractices.org

• This report, which pulls the project findings into a broadpicture of higher education’s response to H1N1 and detailslessons learned, promising practices, and key takeawaymessages that can be used for the next public healthemergency

This report and the Promising Practices Web site are organizedby these key topics:

• Incident management. Years of planning, testing, andrevising plans clearly paid off, particularly in therelationships formed.

• Residence halls. Limited space and a changing clinicalpicture meant successful response required the support ofmany partners.

• Health services. Coping with unprecedented demandrequired all hands on deck, efficient delegation of duties,and creative use of technology.

• Communications. The principle of “one voice, onemessage” was key.

• Vaccine distribution. Many creative approaches were usedto immunize campus communities as vaccines becameavailable.

• Teaching. Academic leaders were essential to addressingthe needs of students and faculty.

• Human resources. Policies sometimes required temporaryrevisions.

• Student engagement. Students provided reinforcementand insight.

• Collaboration with public health partners. Relationshipsbuilt before the pandemic fostered strong results.

In this report, each chapter begins with the lessons learned,includes examples of practices that universities consideredpromising enough to share with their peers, and highlightscompelling quotes and stories. Practices available online (atwww.PublicHealthPractices.org) at the time of publicationare noted with this icon: .

In addition, links cited in the print version of this documentare underlined and in blue type. Readers are encouraged toview the document online (www.PublicHealthPractices.org)to access the links.

H1N1 AND THE BIG 10+2

H5N1 virus responsible for “avianflu” was considered a likely candi-date to launch the first pandemic ofthe 21st century. With this backdrop,university planners began to imaginehow an influenza pandemic mightplay out on campuses.

No stranger to infectious diseaseoutbreaks among students andemergencies on campus that can dis-rupt operations, university plannersat least had some point of referenceto begin their work. But an in-fluenza pandemic akin to the onethat killed so many young, otherwisehealthy adults in 1918 posed a threatthat few at the planning table couldeven envision. And, in fact, planners

were encouraged to expect such1918-like conditions, including 30%or more of students, faculty, andstaff (including planners) ill at thesame time, two or three waves of ill-ness, and a duration that could spanmonths, possibly even years.

And then there were the hard facts.A plentiful supply of an effective vac-

cine would not be available formonths after the pandemic virus wasidentified. Thousands of students liv-ing in close quarters made for less-than-ideal conditions for limitingvirus spread. Overseas students posedunique challenges. At home, clinicswere staffed and scaled for business

One of the groups at higher risk of developing severe

complications such as pneumonia turned out to be of

considerable interest to universities: people younger

than 24 years old.

H1N1 & Higher Ed: Lessons Learned | INTRODUCTION 9

“We have a huge international component. H1N1 in August and September just about killed us. If it went anylonger, we’d be in a heap.”

— Ivy League college

“H1N1 was manageable but tricky at times. It was man-ageable because of the relative mild severity of illness. Itwas a terrible thing to go through, but, given what weplanned for, it was manageable.”

—Ivy League college

“H1N1 nearly killed us. We have a student population of30,000. We were triaging 50 to 60 students a day.”

— Public university in Texas

“The sheer numbers were a challenge. Even though thepandemic was called ‘mild,’ these kids were moderatelyill.”

—Business university in Massachusetts

“H1N1 devastated us.”—Small university in Massachusetts

”“Seen and Heard at American College Health Association MeetingExperiences of Selected Universities

continued on page 10

Mistakes made and corrected during pandemic response arepresented where possible to show the varied approaches andflexibility required. Chapter conclusions highlight the lessonsgleaned, as well as areas for action. A narrative of the collectiveBig 10+2 experience is included as a sidebar to the introduction.

The partner universities who contributed to this report are

typically large land-grant, state-funded, or privately fundedinstitutions, but the principles underlying many of thepractices can apply to small and mid-size institutions. Theauthors hope and expect that most institutions of highereducation will find aspects of their own experiences reflectedin these pages, as well as useful examples that can strengthentheir response to the next public health emergency.

Project staff attended the American College Health Association (ACHA) annual meeting in June 2010 in Philadelphia and heardabout the impact of H1N1 on many universities and colleges nationwide. A key message from that meeting was that small, mid-size, and even some large institutions that did that not have adequate resources, plans, partnerships, or leadership struggled tocope with the surge of ill students. Several breakout sessions addressed the 2009 H1N1 pandemic. The following are quotesfrom presentations and attendees who worked in health services.

as usual—not for surges of very sickstudents. Meanwhile, budget pres-sures continued to build, and somedoubted whether an influenza pan-demic was a risk worthy of attention.

Up against an unfamiliar threat withdire consequences and myriad chal-lenges, universities turned to theirbest source of ideas and support—each other. In January 2006, Big 10universities participated in an onlineconference hosted by the Universityof Minnesota to share strategies anddiscuss planning. Some 25% of atten-dees who responded to a conferencesurvey question said their universityhad not begun planning.

Within 3 years, the picture changedradically. Most universities had organ-ized their pandemic responsethrough an incident managementframework developed by the US De-partment of Homeland Security (DHS)aimed at harmonizing response ef-forts. Universities built strong work-ing relationships with planners frompublic health agencies in their com-munities, conducted tabletop exer-cises and drills, revised plans based onafter-action reports, and met regu-larly. By April 2009 they had re-hearsed for, fine-tuned their responseto, and maintained vigilance arounda threat as yet unrealized.

The difficulties of planning for an un-predictable virus were about to bereplaced by the challenge of re-sponding to an actual pandemic.

Spring 2009The much-feared H5N1 did notlaunch the first influenza pandemicof the 21st century, nor did the novel

influenza virus hail from Asia orAfrica. Instead, it emerged close tohome for Big 10+2 universities at atime when spring allergies becomemore commonplace than flu. Charac-teristic of its capricious nature, theinfluenza pandemic began in North

America during the spring as a resultof a novel H1N1 “swine” flu virus.

And it spread fast, infecting a workerat a University of Chicago healthcarefacility the same week public healthauthorities confirmed that the viruswas a brand new pathogen withpandemic potential. With little harddata to inform decisions, universitiesbegan their response. Some saw littlechoice but to act aggressively to slowviral transmission in case the severescenario they had anticipated wasunfolding and lives were in danger.Several schools activated their emer-gency operations centers (EOCs),while others took a wait-and-see ap-proach. One school immediately gavedoses of antiviral drugs to studentswho were either sick from or ex-posed to the H1N1 virus—and beganto move ill students into isolation.

With Mexico the apparent epicenterof the pandemic, universities can-celled study-abroad trips there andworked to get students home. Theyfielded calls from worried students,anxious parents, and curious re-porters. The virus moved swiftly tomultiple continents, but the scientificpicture emerged more slowly andwith some baffling details.

The 2009 H1N1 influenza virus, as itcame to be known, met the pan-demic criteria established by theWorld Health Organization (WHO),but the illness it caused in most peo-

ple differed markedly from the worst-case scenario. The new virus was be-having much like seasonal influenza,with a few exceptions. One of thegroups at higher risk of developingsevere complications such as pneumo-nia turned out to be of considerableinterest to universities: peopleyounger than 24 years old.

Summer 2009The WHO declared a pandemic onJun 11, 2009. By then, summer campswere under way. Some universitieswere faced with ill campers who re-quired care. All universities hostingcamps and summer conferences de-veloped pandemic procedures.

Universities took advantage of thesummer months to prepare for thecollision of pandemic and seasonal in-fluenza when students returned inthe fall. By this point, the mismatchbetween their plans and the reality ofthe 2009 H1N1 pandemic was becom-ing evident, as was the need to comeup with new strategies. Among them:

Housing. Original plans addressedthe possibility of absentee rates highenough to force university closure.The more likely scenario, plannerssaw, would be that students wouldeither go home to recover or, barringthat option, remain on campus andneed to be isolated from other stu-dents. Schools began to considerhow to support students “self-isolat-ing” in their rooms or apartments.

Surge capacity. Clinicians at oneuniversity were asked to prepare forlong shifts. The hunt for extra helpbegan, and resident assistants (RAs)and students interested in health sci-ences emerged as likely candidates.

10 INTRODUCTION | H1N1 & Higher Ed: Lessons Learned

continued from page 9

H1N1 AND THE BIG 10+2

Flexibility. The surprises offered bythe H1N1 pandemic showed that a“cookbook” response was notpossible. One university draftedguidelines regarding human resourcequestions such as sick leave ratherthan specific protocols. Another onecreated a response logic model thatwas based on “options” rather thanlinking actions to triggers that werenot locally relevant.

Fall 2009As students returned to campus,health services at some schools sawan unprecedented surge of flu-likeillness that required a rapiddeparture from “business as usual.”

Triage. The first task was to ensurethat students with flu symptoms gotthe care they needed and did not in-fect others; another was to discour-age unnecessary visits so that healthservices could manage the patientload. Many clinicians’ jobs werestreamlined so that nurses triaged inperson, online, or by phone, whilephysicians saw only students whomight need medication or other in-terventions. Several universitiesposted online tools to help studentsdetermine the care they needed.

Treatment. Universities used avariety of strategies, includingsending as many sick students to theirparents’ homes as possible; cohorting

students with flu-like illness in specialareas (which turned out to be anunpopular option with students);isolating individuals in single roomswith a bathroom (space permitting);and encouraging sick students to self-isolate in their own rooms until theyrecovered. In the end, the standardmessage was: “If you have symptoms,please return home. If you can’tleave, then self-isolate.”

Students who isolated on campuswere asked to avoid contact withhealthy students, to wear face masksif they entered common areas, and toorder meals that would be delivered.They were generally urged to stayaway from classes until they werefever free for 24 hours without theuse of fever-reducing medication, asrecommended by the CDC.

Follow-up and monitoring. Somestudents received phone calls, textmessages, and e-mails from nurses.Some RAs helped monitor the healthof students on their floors.

Absences. To encourage students tofollow through on self-isolation,administrators at many Big 10+2campuses requested or insisted thatfaculty temporarily suspendrequirements to document illness foran excused absence. Such action wasa frequent source of tension oncampuses, as faculty were often

reluctant to comply and provostsand presidents had to step in attimes to relay expectations andresolve disputes.

Vaccines. Vaccinating the campuscommunity was a high priority.However, the unpredictability ofwhen and which types of vaccinewould be available posed hugechallenges. Those challenges led to a wealth of creative solutions,including adapting existing phoneand scheduling technology forarranging mass vaccination clinics. In the brief period when vaccinesbecame available, students were stillon campus, and willingness to beimmunized was high, universitiesadministered thousands of doses ofH1N1 vaccine to students, staff,faculty, and community members.

Depending on the region, flu-likecases on Big 10+2 campuses peakedfrom late October to early November.Most student health clinics reportedbeing busy but not overwhelmed. Afew, however, had to cease normalclinic functions during peak periods.

Winter 2009-10By the time students returned fromwinter break, influenza activitydropped steeply. Universities wereable to focus primarily on encourag-ing vaccination now that supplieswere relatively plentiful. And as stu-dents left campus for the summer,universities had more time to reflect.They had gained on-the-groundsavvy about responding successfullyto the new pandemic, were in a posi-tion to examine the experience, andwere ready to share what theylearned and what issues still needtheir attention.

H1N1 & Higher Ed: Lessons Learned | INTRODUCTION 11

Many clinicians’ jobs were streamlined so that nurses

triaged in person, online, or by phone, while physicians

saw only students who might need medication or other

interventions.

12 H1N1 & Higher Ed: Lessons Learned

he first influenza pandemic of the21st century caught Big 10+2universities by surprise, but it did notfind them unprepared. For morethan 3 years, cadres of planners hadbeen assembling, testing, and fine-tuning strategies to respond to apandemic of considerablemagnitude. The 2009 H1N1

influenza pandemic unfolded in a much different way, anduniversities veered from some of the plans they had on paper.This chapter examines how institutions approached andadjusted incident management—the system used to respondto an emergency. Following details about each lesson areexamples from the field.

Lessons learned during the pandemic response emphasizedthe following:

• Pre-pandemic planning efforts were invaluable toestablishing relationships and determine roles and resources.Written plans, particularly specific response actions based onexternal triggers, often did not match this pandemic.

• The use of multidisciplinary response teams wasreported as an overwhelming success.

• Integrating pandemic preparedness and response withbroader emergency operations systems, particularlydetermining clear lines of responsibility and authority, was important.

• Universities developed creative solutions to the challengeof coordination and communication among responsepersonnel over an extended response period.

LESSON: Pre-pandemic planning efforts were invaluableThree years before the 2009 H1N1 pandemic occurred,universities were in the midst of planning or had yet to start. Bythe time the novel H1N1 influenza (“swine flu”) virus emergedin the spring of 2009, all Big 10+2 universities had plans in

place to respond to a pandemic scenario that they expectedwould be launched by the more virulent H5N1 (“avian flu”)virus. Written for a more dire but hypothetical scenario, theirplans were not always well-matched to the pandemic unfoldingbefore them. In the end, however, the plans mattered less thanthe planning process itself, which had solidified teams bothknowledgeable and able to work together.

Despite their preparations, many universities had to retooltheir response plans to an unexpected scenario with littlewarning and under public and parent scrutiny. Many of theuniversities said that therelationships and responsesystems they forged andthe sense of familiaritythey developed during theplanning process werecrucial to their ability topivot and respond to the threat at hand.

One example of adapting is evident in the way someuniversities redefined trigger events. Global, federal, and statedesignations of pandemic phases or severity levels did notmatch the reality of the 2009 H1N1 influenza pandemic. Asa result, universities realized that they could not use suchcriteria as triggers to activate their plans. They improvised.

EXAMPLES FROM THE FIELDSwitching to a locally relevant logic model. The

University of Michigan unlinked its plan from the WorldHealth Organization (WHO) pandemic phases, which itfound did not necessarily relate to local conditions. Themodel was meant to trigger actions but actually limitedoptions, planners there noted. Flexibility was the key driverfor decision-making. Planners realized they could recognizedangerous versus manageable situations without relying onspecific numbers or rates, allowing them to adapt more easilyto the H1N1 pandemic or other infectious disease threats.

Infectious Illness Logic Model Aids Planning, Response (MI)

H1N1 & Higher Ed: Lessons Learned | INC IDENT MANAGEMENT 13

CHAPTER 1

IncidentManagementHow prepared were Big 10+2 universities to manage response to the 2009 H1N1 pandemic?

Practices that are available online at the time of publication are noted with this: You can go to thewww.PublicHealthPractices.org Web site for more information on those and other practices.

Planning paid off

KEY TAKEAWAY

‘Options-based’ planning. For The Ohio StateUniversity, keying response to triggers based on illness anddeath rates made the plan too rigid. In laying out its plan inAugust 2009, the university incorporated “options-based”planning, which relied on problem-solving skills rather thanstatic documents and step-by-step procedures. Participantsin the decision-making process varied depending on theissue, but the approach was always to convene the rightstakeholders. The options-based planning worked extremelywell in part because there was strong support from senioruniversity leadership and from those responsible forplanning. “It gave us a little extra freedom to make changesquickly rather than be tied to a black-and-white plan,” auniversity representative said.

Options-Based Planning Allows Flexible H1N1 Response (OH)

LESSON: The key role of multidisciplinary response teamsBy the time the 2009 H1N1 pandemic began, universitieshad created response teams with representatives from manydepartments and functions. Teams took on varying tasks andnames, depending on how the institution approachedemergency response. Examples:

• All-hazards planning group

• Health emergencies response team

• Infectious disease work group

• Pandemic influenza preparedness committee

• ILI (influenza-like illness) committee

• H1N1 oversight team

Universities emphasized the importance of strong leadership,including support from highest levels of administration, andthe integration of health personnel on teams. Also noteworthyfor universities that had large medical centers was the ability tocoordinate incident management efforts with them.

How groups formed, evolved, and were integrated intopreparedness at Big 10+2 universities varied. But plannersalmost universally agreed that optimal teams had strongsupport from leaders, represented a broad spectrum ofuniversity functions, and included health personnel.

EXAMPLES FROM THE FIELDBeginning with support from the top. Beginning in

2006, the University of Wisconsin-Madison (UW) madepandemic influenza planning a priority as initial supportcame directly from the chancellor’s office. Given that the UWPolice Department (UWPD) oversees emergencymanagement on campus and that the chief of police is alsoan associate vice chancellor, the UWPD became significantlyinvolved in pandemic planning and H1N1 response.

University health services and the university police formed theCampus Health Issues Planning (CHIP) Committee, whichbuilt relationships and communication protocol betweenhealth services, police, university communications, humanresources, housing services, occupational health, the dean ofstudents, the registrar’s office, and the provost. From 2006onward, UWPD ensured that campus organizations anddepartmental deans, chairs, and directors were trained on UW’spandemic plan and continuity of operations plan (COOP).

Virtual EOC Is Campus Base of Operations (WI)

One lead, three backups. The University of MinnesotaEmergency Operations Plan includes provisions for a HealthEmergency Response Team charged with providing high-levelconsultation related to any health-related emergency on

University of Wisconsin-Madison

Example: Running a Virtual EOCCampus police managed a virtual EOC to free others for key response activities, allowing some return to normal duties.

Close partnerships and regular communication allowedthe University of Wisconsin-Madison Police Department(UWPD) to manage campus H1N1 response and main-tain situational awareness—essentially functioning asthe eyes and ears of the virtual Emergency OperationsCenter (EOC).

The police department and University Health Services(UHS) had a long history of collaboration on emergencyplanning. When the pandemic occurred, police estab-lished an EOC in a conference room, where the UHS di-rector served as incident commander. After several weeks,the incident management team switched to a virtualEOC, which allowed health, police, and communicationsstaff to perform their emergency functions while also re-turning to their usual roles on campus.

The virtual EOC changed the way university departmentscommunicated. UWPD used an e-mail platform to handleEOC-related communication with health services, hous-ing, the registrar, the state health department, and otherbranches of the university system. UWPD retained overallmanagement of the virtual EOC and assumed severalhealth services administrative tasks. By ordering masksand distributing basic communications materials, theUWPD freed UHS staff to open a triage phone line andprovide care to students.

NOTES FROM THE FIELD

14 INC IDENT MANAGEMENT | H1N1 & Higher Ed: Lessons Learned

campus. A Pandemic Influenza Response Plan is an annex tothe broader plan. The plan outlines specific and detailedresponse actions in distinct areas such as communications,campus infrastructure, teaching, and research. In addition, alarger pandemic influenza response team was formed bydesignating four employees in each response area (one leadand three backups for redundancy). During the pandemic,these employees had authority to represent their respectiveresponse area in an incident command structure.

Pandemic Influenza Response Team (MN)

LESSON: The importance of integrated response, clear lines of responsibility Many chose, trained in, and worked successfully with theNational Incident Management System (NIMS). NIMS offers aframework for all-hazards planning that shares terminology,concepts, and processes. NIMS is a requirement for allagencies receiving federal preparedness funds, so adoptingNIMS allows universities to coordinate planning and responseefforts with surrounding jurisdictions and organizations.Personnel involved in pandemic planning could get NIMStraining through the Federal Emergency Management Agency(FEMA). Most of the Big 10+2 universities adopted the NIMSframework for emergency operations.

EXAMPLES FROM THE FIELDUsing NIMS training. By spring of 2009, some 1,500

people at the University of Illinois had gone throughincident command training. Illinois’ director of emergencyplanning oversaw NIMS training for administrative, academic,and operational personnel throughout campus, as well as formulti-jurisdictional partners.

Prepared leaders. Purdue University—which adoptedNIMS and used online FEMA training for many seniorpersonnel—launched its planning work in 2005 by creating apandemic preparedness committee with membership from allareas on campus as well as local public health and emergencymanagement partners. Although the campus did not activatean EOC during the 2009 H1N1 influenza pandemic, keypersonnel from the preparedness committee assumedleadership roles. The experience showcased the value of NIMS.

LESSON: Long-term coordination and communication require creative solutionsEven before the WHO made its official declaration on June11, 2009, many Big 10+2 university response teams weremeeting face-to-face and via conference call weekly, daily, ormore frequently. The pace and intensity that response teamsencountered, particularly at the start of the pandemic, couldnot be sustained for 7 months, when cases of illness peaked.In addition, while broad representation on response teamswas seen as a strength, it also came with challenges.

Coordinating and communicating with large teams,especially when an institution had multiple levels ofredundant representation, required extra effort. Whenmeeting in person was not practical, universities relied onvideo and phone conferencing, listservs, and e-mails.Maintaining teams for the duration of the pandemic wasanother challenge. Most campus incidents (fires, floods, actsof violence) occur over hours or days, while the pandemicresponse spanned many months.

EXAMPLES FROM THE FIELDOnline meetings. Indiana University health services

anticipated in April 2009 that H1N1 would be a problem oncampus and quickly activated the EOC. Individuals involvedin response met online at a given time each day or week, andresponders from all eight campuses were able to share dataand coordinate efforts. In addition to being able to haveconversations about activities happening in the universitysystem across the state, participants could view current,comprehensive information about the unfolding situation.

In-person briefings with full team, plus consistent,two-way e-mail communications. The pandemic influenzaresponse team at the University of Minnesota, some 75members strong, met in person twice in the EOC for briefingmeetings. Though logistically challenging, the on-site meetingsprovided an important opportunity for team members,particularly back-up employees, to experience the physical set-up and check-in requirements at the EOC. Video conferencingwas used to include coordinate campuses in the universitysystem. E-mail communications were used as needed to keepteam members informed. To ensure ongoing awareness,written situation reports from each response area were

H1N1 & Higher Ed: Lessons Learned | INC IDENT MANAGEMENT 15

What Is the National Incident Management System?NIMS is a comprehensive, national approach to incidentmanagement that is relevant for all jurisdictional levelsand across functional disciplines. It is intended to:

• Be applicable across a full spectrum of potential inci-dents, hazards, and impacts, regardless of size, location,or complexity

• Improve coordination and cooperation between publicand private entities in a variety of incident managementactivities

• Provide a common standard for overall incident management

Source:http://www.fema.gov/emergency/nims/FAQ.shtm#item1c

TOOLS FROM THE FIELD

Lessons Learned Recap

• Pre-pandemic planning efforts were invaluable to establish relationships and determine roles and resources. Written plans, particularly specific response actions based upon external triggers, often did not match the H1N1 pandemic.

• The use of multi-disciplinary response teams was reported as an overwhelming success.

• Integrating pandemic preparedness and response with broader emergency operations systems, particularly determining clear lines of responsibility and authority, was important.

• Universities developed creative solutions to the challenge of coordination and communication among responsepersonnel over an extended response period.

Actions and Challenges Ahead Include

• Maintaining and supporting campus response teams, in whatever form works best for each institution, to ensure a continued state of readiness.

• Documenting and sharing successes related to coordination and communication among response team members.

• Revising response plans to remove triggers tied to WHO pandemic phases and US stages and/or severity index.

collected, compiled, and shared as needed. To safeguardcommunications, members of the university response teamcreated secondary e-mail addresses for messages. Theuniversity also created an automated phone notificationsystem that could be used in rare situations if team membersneeded to be notified quickly by phone. Office, home, andcell phone numbers were included in that system.

Pandemic Influenza Response Team (MN)

Moving to a virtual EOC. The University of Wisconsin-Madison switched to a virtual EOC, which allowed health,police, and communications staff to perform emergencyfunctions in addition to their usual roles on the campus. Thepolice department was accustomed to operating 24 hours aday, so communicating via a virtual EOC was fairly efficient.Communication strategies, however, had to change. Whereasstaff could communicate in-person or via a white board inthe physical EOC, the virtual model required much closercollaborations with a variety of on-campus organizations.

Virtual EOC Is Campus Base of Operations (WI)

Well-organized incident management that builds onrelationships is especially important in university responseto long-term emergencies.

16 INC IDENT MANAGEMENT | H1N1 & Higher Ed: Lessons Learned

For details please see the Higher Education section of

CIDRAP’s Promising Practices site.Purdue University

Internal Memoranda of Understanding for Point ofDispensing Sites (IN)

University of MichiganInfectious Illness Logic Model Aids Planning, Response (MI)

University of MinnesotaHealth Department Operations Center (MN)

Pandemic Influenza Response Team (MN)

Workforce Absenteeism Exercise (MN)

University of WisconsinMHUB Communication Tool for Students, Staff, andFaculty (WI)

Virtual EOC Is Campus Base of Operations (WI)��

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Incident Management Practices Online

THE POST-H1N1 LANDSCAPE: INCIDENT MANAGEMENT

ig 10+2 university students whodeveloped a flu-like illness during the2009 H1N1 influenza pandemic wenthome to recover, were encouraged toself-isolate in their own rooms, or,rarely, were moved into a limitednumber of special rooms for isolation.By and large, universities hadn’tplanned to house the number of sick

students they did. Because pre-pandemic planning assumedeven greater numbers of students would become ill with moresevere symptoms, universities were expecting to rapidly closeresidential housing, send the vast majority of students home,and care for the few unable to leave, whom they assumedwould be mostly international students.

Though thousands of sick students did return home torecover during the fall wave of the H1N1 pandemic, enoughremained on campuses to prompt the Big 10+2 universitiesto revamp housing plans, abandon certain assumptions, andfurther adjust as more epidemiologic information about thepandemic became available. This chapter examines howinstitutions addressed the issue of influenza prevention andcare in residence halls. Following details about each lessonlearned are examples from the field.

Lessons learned during the pandemic response emphasizedthe following:

• Specific procedures for summer camps hosted on campusare an important component of pandemic influenzaresponse plans.

• Designating isolation housing for symptomatic studentsor relocating students can be challenging due to housinglogistics and student preferences.

• Sending symptomatic students home for a specifiedperiod can be successful.

• If multiple campus supports are in place, students whocannot or choose not to go home can successfully self-isolate in their residence hall rooms.

• Student leaders did and can continue to play animportant role.

LESSON: Summer camp procedures are importantUniversities that hosted residential summer camps wereamong the first to feel the pandemic’s impact. Preemptivecommunicationswere sent tocamp organizersasking families tokeep sickcampers at home.With most of thestudent bodyaway, sickcampers could be isolated in unoccupied dorms. Universitiesalso provided treatment to campers and prophylaxis to staff ascircumstances or guidance warranted.

LESSON: Dedicated isolation housing can bechallengingExtra housing capacity quickly disappeared in the fall. Forsome universities, H1N1 cases appeared the first day of fallclasses. Early media images showing colleges with plenty ofspace to house and isolate sick students in no way resembledthe Big 10+2. Even with limited empty space, someuniversities implemented isolation approaches, includingcreating designated spaces and housing sick studentstogether. Use of dedicated isolation housing was successful insome instances but showed mixed results in others. Inaddition to logistical problems, some found that somestudents, both the sick and the well, were not supportive ofthese plans, even when based on public healthrecommendations. Engaging students in planning, response,and trouble-shooting led to successful outcomes.

EXAMPLES FROM THE FIELDDesignating isolation rooms. Housing services at the

University of Illinois, which had committed to locatingspace to isolate students who could not return home,designated 12 “medical rooms” early in the pandemic. Somestudents stayed for the full course of their illness; othersstayed until a parent transported them home. Housing staffwould contact those students daily (usually via phone) for a

H1N1 & Higher Ed: Lessons Learned | RESIDENCE HALLS 17

CHAPTER 2

ResidenceHallsHow did schools control the spread of H1N1 in crowded residence halls andensure that sick students had adequate room and board as they recovered?

Successful housing

response depends on

many campus partners

KEY TAKEAWAY

nonmedical check-in. Ill students could review the campusdining service menu online and place an order for delivery byhousing staff. Staff also stocked in-room refrigerators withsports drinks and healthy snacks. The rooms were furnishedwith linens, TV, furniture, and Internet. On average, fourstudents a day used the rooms, and each needed about 5 daysto recover. At the peak of H1N1 illness on campus, 11 of 12rooms were in use. As the number of cases dropped, housingleaders transitioned to a system of self-isolation.

Self-Isolation: The On-Campus Option (IL)

Cohort isolation. One of the first of the Big 10+2 to havea laboratory-confirmed H1N1 case, the University ofChicago asked students not affected by the virus to relocate,so potentially ill students could move into housing thatprovided private bathrooms and areas that could be easilyclosed off. Students pushed back when the designatedresidence halls were identified. In one case, sick students wereto be relocated to an empty floor of a facility normallydesignated for international students in their 30s and 40s, andvisitors to the university. Existing residents, however, voicedstrong concerns about the plan and called for a meeting withcampus administrators. Officials learned that healthy studentswere willing to be around someone with H1N1 if the personwas someone they knew well and was a part of thecommunity, but they were concerned about having sickpeople they didn’t know move into their area. In response tostudent concerns, the university revisited its housing plansand included students in developing the next iteration, whichproved successful.

Students Developed Housing Plan in Response to H1N1 (IL)

LESSON: Recovery at home can be a successful strategyAn important strategy to mitigate H1N1 spread was toencourage sick students to recover at home. In preparationfor fall classes, provosts, housing and student affairsdirectors, and other administrators sent letters and e-mails tostudents and parents requesting that sick students stay homeuntil they recovered. Students who developed symptoms afterarriving on campus were asked to return home, if possible.For the most part, this approach succeeded. Complicationsarose on occasion, when physicians told students they couldreturn to campus before the recommended self-isolationperiod had ended.

EXAMPLES FROM THE FIELDSending students home. The University of Illinois

described its approach as one of the most aggressive in thenation. On the first day of school, the university decided thatit would send home as many sick students as possible. Moststudents had homes within a 3-hour drive, and 12,000students lived on campus. Illinois set up a special clinic to seeonly people with flu-like symptoms. Sick students wereencouraged to contact family members to pick them up.

Most students were able to use their cell phone and callparents while the students were still with healthcareproviders. Some parents became sick after being exposed totheir students, but the university reported overall success withthe approach.

LESSON: Self-isolation in residence halls requires added support Most Big 10+2 university students who had flu-like symptomsand could not leave campus were asked to self-isolate in theirrooms. The success of self-isolation depended on studentcompliance, having students’ concerns addressed by healthcareproviders, easy access to food and self-care items, and carefulmonitoring of students by health services staff, housing staff,RAs, or others. Several universities relied heavily on technologyto link sick students with dining and health services and tolook after them. Online and telephone contact (typically withnurses who used triage and follow-up protocols) was asuccessful practice at some universities. Ordering meals onlineallowed in-room meals to be delivered by dining services staff,roommates, or other students. Self-care kits were provided andincluded face masks, disposable thermometers, fever-reducingmedications, hand sanitizer, and health information.

Universities reported working closely with Greek societies onthe same measures. Though isolation housing was a newconcept, fraternities and sororities joined the effort to isolatesick students. The unique needs of international studentswere also addressed.

EXAMPLES FROM THE FIELDMedical monitoring. Ill students at the University of

Wisconsin-Madison who had been diagnosed by nurses viatelephone triage received text messages with tips on how to

18 RESIDENCE HALLS | H1N1 & Higher Ed: Lessons Learned

In addition to simplifyingrecovery efforts for those affected,isolating ill students helped reduceconcerns for the broadercommunity and other students’parents. I’m obviously concernedabout the student who is ill, butalso the other 50 they live with.

Jim Rooney, EDDAssociate Director of Housing

University of Illinois

TIP FROM THE FIELD

care for themselves. Students could also call or e-mailquestions. Follow-up monitoring at Pennsylvania StateUniversity allowed health services to identify signs thatcertain students were developing pneumonia; this step mayhave prevented the need to hospitalize them. In general,universities that provided follow-up reported that bothstudents and parents expressed appreciation.

Meal support. The University of Iowa created a specialisolation meal pack that included items such as fruit juice,sports drink, granola bars, soup, crackers, sandwiches, andcereal. Isolated students could request the meal pack online.If students did not have a friend who could pick up the pack,dining services would deliver it. Many other universities useda similar approach.

Monitoring student compliance. Students who wereseen in the ILI clinic at the University of Illinois signed aform that allowed health services to contact housing, faculty,and the dean of students and share health informationrelevant to the student’s illness. Most students complied withisolation procedures. The few who did not were monitored,contacted by the dean’s office, and reminded that isolationwas for the benefit of others.

LESSON: Student leaders played an important roleAnother significant resource was students. RAs, roommates,health advocates, peer health educators, and internationalstudent groups made important contributions to monitoringand caring for their peers; developing, revamping, andproposing alternative housing plans; and buildingcommunity partnerships.

EXAMPLES FROM THE FIELDTraining RAs. The Office of Residence Life at the

University of Iowa trained RAs to respond to ill students.Checklists, scripts, and protocols were created for assessingpotentially ill students and responding to inquiries fromparents and students. Rather than asking RAs to makedecisions about referral or treatment, the protocol wasdesigned to encourage students living in residence halls tocommunicate their needs and for RAs to have what theyneeded to help students access various levels of healthcare.The guidelines also encouraged RAs to practice socialdistancing and maintain the privacy of a student’s conditionwhen friends and families inquired.

Resident Assistant Checklist for Assessing Students (IA)

Providing peer support through health advocates.Health advocates at the University of Minnesota arestudents serving as health resources where they live, such asin their residence hall or apartment, fraternity, or sorority.

H1N1 & Higher Ed: Lessons Learned | RESIDENCE HALLS 19

University of Minnesota

Health Advocates’ Role in H1N1 ResponseEmma Casey is a public relations major at the Universityof Minnesota. She worked as a health advocate in a resi-dence hall during the H1N1 response. It was a natural ex-tension of the existing health advocate activities, whichcan include first aid for minor injuries or providing sexualhealth information.

“Our work providing H1N1 information to students waseasy, because the students naturally come to us for allkinds of information anyway,” Casey said. “We have acode of conduct that values confidentiality, and the stu-dents know that, so [the] information we gave them orthey shared with us will not be leaked. For me, to be seenas a resource that students could trust was important.”

The health advocates program was expanded to help thecampus community address H1N1 response in severalways:

• Health advocates received special training related toH1N1 and campus response procedures and instructionon how to detect and report symptoms of flu-like illness.

• Each advocate was fitted with an N95 respirator andgiven a supply of surgical masks to hand out to stu-dents with flu-like symptoms and their roommates.

• Health advocates learned when students with flu-likesymptoms should just stay in their rooms and rest andwhen symptoms necessitated care at the health service.Health advocates also were trained to call the 24-hournurse line to help inform their decisions.

They were reminded that residence hall students couldhave meals delivered to their rooms instead of going tothe dining hall. The residence hall directors could contactan advocate if a student needed a meal delivered.

• They received specially equipped messenger bags withpre-made packages of thermometers and over-the-counter medications.

• Advocates were surveyed during weekly classes to determine how prevalent flu symptoms were in the residence halls and fraternities and sororities.

NOTES FROM THE FIELD

continued on page 20

Health advocates attend weekly training at the student healthservice for common health issues, receive first aid and CPRcertification, and are offered the opportunity to earn twocredits each semester through the School of Public Health.They share information and prevention strategies with otherstudents and also refer students to other health resources oncampus. During H1N1 response, health advocates providedfrontline public health interventions in all types of studenthousing. The health advocates program is one of severalinitiatives supported by a portion of student services feesdedicated to public health on campus.

Student Health Advocates Also Address H1N1 (MN)

Engaging international student groups in creatinghousing plans. At Michigan State University (MSU), theOffice for International Student Services (OISS) workedclosely with international students and many on-campusinternational student groups to plan for emergency housing.One of the groups is the MSU International StudentsAssociation, whose membership includes more than 4,000international students. Most of the outreach and planning forinternational students came from informal conversationsbetween OISS and the students themselves, demonstratingthe students’ ability to advocate and prepare. In addition, theinternational community on MSU’s campus connected withEast Lansing residents and organizations, demonstrating the

strength and breadth of the support system available shouldit be needed. Student groups reached out to families andcongregations in East Lansing, and students often said theyknew someone in the community whom they could ask forhelp. The plan did not have to be activated for the H1N1pandemic, but the process strengthened ties between theuniversity and the East Lansing community.

International Students Participate in Planning Alternative

Housing (MI)

Universities responded to the challenge of housing illstudents in a number of ways during the H1N1 pandemic,including sending ill students to recuperate with theirparents and finding ways to isolate them in their homes. Bytesting strategies to limit the spread of influenza oncampus, universities have identified some successfulapproaches, as well as areas for improvement. Closercollaborations with students and public health partners atall levels of government can strengthen response to studenthousing issues.

University of Wisconsin-Madison

Housing Letter to Studentswith Flu-like Illnesses Dear Residence Hall Resident,

You have been confirmed to have flu like symptoms.Please remember that it is our expectation that you gohome, which is the best place to recuperate. If you areable to leave campus without the use of publictransportation, you should contact your family to makenecessary arrangements.

You will also need to contact your House Fellow orResidence Life Coordinator upon your return to theresidence hall to prepare for your arrangements. You canalso talk to them if you are having difficulty leavingcampus. Please note that you should wear a mask whileremaining in the residence hall community.

For specific information regarding influenza, please referto the campus’ website: flu.wisc.edu.

Sincerely,University Housing

NOTES FROM THE FIELD

For details please see the Higher Education section of

CIDRAP’s Promising Practices site.Michigan State University

International Students Participate in PlanningAlternative Housing (MI)

University of ChicagoStudents Developed Housing Plan in Response to H1N1 (IL)

University of Illinois Self-Isolation: The On-Campus Option (IL)

University of IowaMeal Pack for Isolated Students (IA)

Resident Assistant Checklist for AssessingStudents (IA)

University of MinnesotaFacemask and N95 RespiratorRecommendations (MN)

Student Health Advocates Also Address H1N1 (MN)

University of Wisconsin-MadisonTelephone Triage and Treatment Protocol (WI)�

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�Residence Halls Practices Online

20 RESIDENCE HALLS | H1N1 & Higher Ed: Lessons Learned

Lessons Learned Recap

• Specific procedures for summer camps hosted on campus are an important component of pandemic influenza response plans.

• Designating isolation housing for symptomatic students or relocating students can be challenging due to housinglogistics and student preferences.

• Sending symptomatic students home for a specified period can be successful.

• If multiple campus supports are in place, students who cannot or choose not to go home can successfully self-isolate in their residence hall rooms.

• Student leaders did and can continue to play an important role.

Actions and Challenges Ahead Include• Expanding pandemic influenza response plans to include less-severe scenarios based upon what worked and what

did not work in 2009 and 2010.

• Increasing communication between universities and the CDC on the development of higher education guidelines,particularly related to residence hall recommendations.

• Possibly boosting the role public health partners play in educating family clinicians about the importance of reinforcing self-isolation recommendations for symptomatic students.

THE POST-H1N1 LANDSCAPE: RESIDENCE HALLS

H1N1 & Higher Ed: Lessons Learned | RESIDENCE HALLS 21

22 H1N1 & Higher Ed: Lessons Learned

aced with a surge of sick students duringthe 2009 H1N1 pandemic, healthservices at the Big 10+2 universities metthe demand by streamlining job duties;expanding capacity with volunteers,students, and additional providers; andleaning heavily on phones, computers,and online technology. Although“business as usual” in health services fell

away to long hours that stretched over weeks, particularlyduring the fall, university clinics for the most part reportedbeing “busy but not overwhelmed.” Nonetheless, thepandemic tested health services preparedness as no exercisecould, pointing out weak spots but also highlightinginnovation and the importance of a flexible response.

Lessons learned during the pandemic response emphasizedthe following:

• College-aged students were among the groups of peoplemost at risk of developing complications from H1N1infection. Universities became important sites for care,with campus health services playing a key role.

• Streamlining operations was a successful approachto maintain quality and effectiveness within the healthservice.

• Online and phone-based triage systems were usedeffectively to provide care information and referrals topatients.

• Prescribing self-isolation and home care can be asuccessful strategy if adequate support systems are put inplace.

• Campus partners were available to provide additionalstaff support within the health service.

• Students played an important role in providinginformation and care.

LESSON: College-aged students were at riskfor H1N1 complicationsAlthough some campuses were affected earlier in the year, thebiggest wave of sick students needing health services began to

build in the fall.By then, evidencehad emerged thatcollege-agestudents wereamong the groupsof people most atrisk of developingcomplications(pneumonia forexample) fromH1N1 infection and therefore required extra watchfulness.Young people between the ages of 5 and 24 also had thesecond-highest rate of hospitalizations, according to theCDC. Because institutions of higher education serve millionsof young people in this risk group, many of whom are awayfrom home and sick at the same time for the first time, healthservices became busy hubs of pandemic response.

EXAMPLE FROM THE FIELDDrawing on redesign principles. The University of

Chicago needed to act quickly in late April 2009 when itdiscovered that a medical center employee was diagnosed ashaving H1N1. Charged with the health of 15,000 students,the director of the Student Care Center (SCC), a separateoperation, faced several challenges:

1. Limited information. Data on the scope of the threatwould not be available for weeks.

2. Small staff size. The SCC has the smallest clinical staffper student of the Big 10 + 2 schools, according to thedirector—three nurse practitioners, two medical doctors,five nurses, and five front office and administrativesupport staff.

3. Space limitations. The SCC occupies 3,600 square feet ofspace.

The clinic director used principles of quality improvementand healthcare redesign, one of her areas of expertise, todetermine how to quickly, efficiently, and carefully serve thelarge population with limited resources. She and the SCCstaff, for example:

H1N1 & Higher Ed: Lessons Learned | HEALTH SERVICES 23

CHAPTER 3

Health ServicesHow did health services meet the surge in demand created by the pandemicwhile ensuring qualified help over extended periods?

An all-hands-on-deck

approach was needed,

as was the tenet of

‘divide & conquer’

KEY TAKEAWAY

• Began triage operations in a ventilated campusparking garage until a better arrangement could be made

• Developed a partnership with the University ofChicago Medical Center to take over standard studenthealthcare needs so the SCC could handle H1N1 screeningand testing cases

• Participated on the Medical Center’s Bio-OutbreakTask Force to discuss information and adjust plans asneeded

Quality Improvement Redesign a Tool in Pandemic Planning

and Response (IL)

LESSON: Streamlining operations was successful Big 10+2 universities took advantage of the summer monthsto gear up for a possible surge of students with influenza.Members of the health services staff at Indiana University,for example, were notified that demands on their time mightincrease and could affect vacation requests and prompt aneed for weekend/evening shifts. For maximum efficiencywhen the surge began, some health services narrowed thescope of clinicians’ jobs so that nurses, for example, focusedon triage, data collection, and follow-up, while physicianstreated students with conditions that upped their risk ofcomplications or who needed antiviral medication.

Creating and standardizing H1N1 protocols, forms, andrecommendations as much as possible also saved time.Campuses that could put online newly created H1N1-specificprotocols and data collection documents or link them toelectronic medical records saw even more benefits, such asstreamlined follow-up with sick students.

EXAMPLES FROM THE FIELDFrom nurse to ‘flu’ nurse. Six primary care nurses at the

University of Wisconsin-Madison were reassigned fromdirect patient care to advising ill students by phone. As newepidemiologic information became available (eg,hospitalization rates and who was most vulnerable tocomplications), the CDC would revise and refine its guidance.Keeping up to date with the rapid-fire release of new data andnew guidance required a level of expertise that the primarycare nurses had, owing to their extensive training.

Telephone Triage and Treatment Protocol (WI)

Quick and convenient care. After students, staff, andfaculty expressed a desire for faster, more convenient, and moreaffordable options for healthcare on campus, the University ofMinnesota health service opened the Gopher Quick Clinic.The Quick Clinic is a convenience care clinic staffed by certifiedpractitioners trained to diagnose, treat, and write prescriptions.Care is provided on a first-come, first-served basis, with mostvisits lasting about 10 minutes. Patients are seen for common

illnesses, skin conditions, vaccines, and pregnancy testing only.According to the health services director, having the GopherQuick Clinic established prior to the arrival of H1N1 helpedstaff to successfully meet the sudden demands for care. TheQuick Clinic enabled large numbers of patients to be seenwithout placing undue pressure on clinicians. Only the sickestpatients were referred to the regular primary care clinic, whichallowed the health service to maintain a consistent level ofservice throughout the pandemic.

LESSON: Online and phone-based triagewas used effectively Discouraging unnecessary clinic visits while ensuring that illstudents who truly required services were seen became astrategy for some universities to both slow transmission ofdisease and manage the clinic workload. Materials andprotocols had to be developed that allowed students to screenthemselves using online tools. For consistency, qualityassurance, and smooth workflow, nurses who triaged studentsvia phone also needed protocols that standardized questionsand allowed them to enter information online. Where suchtools were developed and used, Big 10+2 universities reportedsuccess and expressed confidence with the approach.

EXAMPLES FROM THE FIELDSelf screening. Northwestern University created two

online screening forms—”I think I may have H1N1influenza” and “I think I may have been exposed to H1N1influenza”—that guided students through an algorithm ofquestions to “outcomes” that either reassured them that theycould manage with self-care or alerted them that they shouldschedule a clinic visit. The service received praise fromparents who were also physicians.

Tools for ‘flu’ nurses. The University of Wisconsin-Madison, where nurses screened and triaged up toapproximately 100 calls a day as soon as the fall semesterbegan, leaned heavily on protocols that connected to theschool’s electronic medical record. These included:

• Nurse protocol for management of flu-like illness whenH1N1 is widespread

• Nurse telephone triage and management of flu-like illness

• Nurse visit—initial assessment

• Nurse visit—initial visit for flu-like illness Telephone Triage and Treatment Protocol (WI)

LESSON: With the right support, self-isolationand home-care strategies can succeed CDC guidance recommended that institutions of highereducation “promote self-isolation” by residential students andoff-campus residents, that, where possible, students return

24 HEALTH SERVICES | H1N1 & Higher Ed: Lessons Learned

home, and that, for students who could not leave campus anddid not have a private room, schools consider providingtemporary alternative housing. For Big 10+2 universities,where housing tends to be tight and where there also may belarge contingents of international students who cannot gethome easily, trying to provide separate housing was often notpractical. Still, Big 10+2 universities made every effort to meetthe guidance. They encouraged ill students to recover at home,promoted self-isolation by providing self-care guidance and“flu kit” supplies, set up ways for students to have mealsdelivered, and engaged residence hall staff to help monitorthe health of students. Phones, e-mail, and electronic medicalrecords provided means for nurses to stay in touch withstudents diagnosed as having flu-like illness.

Some universities that followed CDC guidance and senthome students with flu-like illness later learned that familydoctors may not have been as familiar with the guidance andwould question the school’s actions. This confused studentsand parents. Several Big 10+2 universities have asked theCDC to address this issue in the future by unbundling suchrecommendations from the guidance and highlighting themas separate documents that universities can reference whenthey take action.

EXAMPLES FROM THE FIELDSending ill students home. Promoting isolation was a

central tenet of pandemic response efforts at the Universityof Illinois. A communications campaign explained the self-isolation plan. Staff at McKinley Health Center reorganizedthe facility to allow a separate triage and treatment area forstudents with flu-like illness. Students were asked to reviewand sign a one-page form that collected their current contactand housing information and provided authorization toshare health information relevant to their illness. This helpedclinicians identify potential infection control issues (such aswhether the student lived in a dormitory or a fraternity orsorority). Most students signed the form before seeing aclinician. Most students diagnosed as having flu-like illnesscalled their parents or accepted the clinician’s offer to explainthe students’ needs to parents. Some 90% of the 2,000students diagnosed as having ILI went home.

Self-Isolation: The Family Home Option (IL)

Staying in touch. Following up with ill students atPennsylvania State University meant tracking their illnessdaily by phone or through secure electronic messages.Having an electronic medical record made it possible for thecollege’s information technology staff to run daily reports ofwhich students were seen for flu-like illness at the campushealth service and local hospital. Students were notifiedduring their clinic visit that their condition would bemonitored either until they went home or until theirsymptoms improved. Students who stayed in their residencehalls or in off-campus housing were contacted by phone orthrough secure e-mail. Nurses found quite a few students

whose symptoms were worsening, many of whom werediagnosed as having pneumonia. The number of studentscontacted reached 80 to 100 a day by week 10. Students andparents appreciated the daily contacts, especially during thefirst few days of illness when students felt the worst, auniversity representative noted. Early detection of worseningsymptoms prompted a continuous reinforcement of self-careadvice. Of more than 2,200 patients treated, only 2 studentswere hospitalized with influenza-related complications.

Phone Monitoring of Students With ILI (PA)

LESSON: Campus partners provideadditional staff support Most of the Big 10+2 universities needed extra help at somepoint during the fall of 2009, and health services built surgecapacity with volunteer clinic greeters and clinicians, publichealth and nursing students, peer health educators, temporarynurses, and staff from other campus departments and services.For the most part, enough extra help was available that healthservices remained busy but not overwhelmed. Not alluniversities, however, were able to maintain routine clinicservices during the peak of student illness. Two schoolsreported the need to suspend standard operations for up to 4 weeks during peak periods so providers could focus onexamining patients with flu-like illness.

EXAMPLES FROM THE FIELDAdding clinical staff. The University of Wisconsin-

Madison health services is typically staffed by an on-callclinician during Labor Day weekend. But in 2009, a surge ofcalls from sick and worried students came that first week ofSeptember, before the semester began, overwhelming the onestaff member and making clear the need to ramp up servicesimmediately. The university was compelled to open the clinicwith physician volunteers to screen and treat students. Evenone psychiatrist volunteered to see students. A nurse from theWomen’s Health Clinic was recruited to help when primarycare nurses were reassigned to work the phone.

Telephone Triage and Treatment Protocol (WI)

H1N1 & Higher Ed: Lessons Learned | HEALTH SERVICES 25

Pennsylvania State University

Nurse Follow-up Phone ContactStudents with ILI were contacted by nurses after diagnosis

Week during fall semester Students contacted per week

Week 1 25-30

Week 3 150

Weeks 4-10 560-700

TIP FROM THE FIELD

Help from epidemiologists. Two universities cited thevalue of having an epidemiologist help health servicesinterpret rapidly changing information. By collaborating withthe medical center and joining twice-daily meetings of a smallgroup that included administrators, clinician “champions,”and an epidemiologist, health services at the University ofChicago was able to get quick answers and solutions at a timewhen local and state public health agencies were stretchedthin. At the University of Wisconsin-Madison, the campusepidemiologist, a physician’s assistant, monitored CDCguidance on treatment, prophylaxis, and laboratory testing toensure the health services staff were informed and knew tofollow the same protocol. He synthesized the informationand prepared a daily “Influenza Update Letter” with thenumber of triage calls handled the previous day, new CDCguidelines, and requirements for submitting potential H1N1samples for testing.

Relying on help from residence halls. Staff from theOffice of Residence Life and Student Health Service at theUniversity of Iowa developed checklists and scripts that RAsand full-time professional staff could follow as they assessedpotentially ill students and responded to inquiries fromparents and students. Checklists and scripts were gearedtoward different roles in residence hall management. Aresponse protocol for the 24-hour residence hall help deskaddressed how to respond to reports of student illness. Ratherthan asking RAs to make decisions about referral or treatment,the protocol asks students to communicate their needs andpresents the RA with healthcare and transportation resourcesto offer.

Similarly, extensive guidelines for RAs and full-timeprofessional housing staff provided information they neededto respond to student and parent inquiries. The algorithm

included information on how to access various levels ofhealthcare for an ill student, including availability oftransportation and phone consultations, how to order mealpacks for students unable to leave their rooms, and how toobtain other materials, such as face masks and gloves. Theguidelines also describe some expectations of RAs andprofessional housing staff and how they can encourage/practice social distancing and maintain the privacy of astudent’s condition from inquiring parents or friends.

RAs monitored ongoing illness within their halls, doing ahead count of ill students each week and reporting thenumber at weekly staff meetings.

Resident Assistant Checklist for Assessing Students (IA)

LESSON: Student leaders provided information and careAs major stakeholders in the universities’ pandemicresponse—and an energetic and creative resource to tap—students helped health services avoid incorrect assumptionsand misunderstandings. Cadres of Big 10+2 studentseducated their peers about 2009 H1N1 pandemic influenza,served as a trustworthy source of answers to questions fromfellow students and response teams, assisted with infectioncontrol efforts, and, with training and supervision, evenadministered H1N1 vaccine. For their efforts, some studentsreceived course credits and some were paid. One student saidher experience was life-changing.

EXAMPLES FROM THE FIELDInfection control internships. As the fall 2009 semester

and the threat of novel H1N1 loomed at PennsylvaniaState University, the infection control nurse manager atUniversity Health Services recognized she needed help.Outreach to the university’s schools of nursing and healthpolicy administration rallied four undergraduate interns.They helped collect data and run the flu clinics. They evendonned a “flu bug” costume to promote H1N1 prevention.The internships contributed 36 hours a week of help, andstudents earned credits toward their degrees.

Infection Control Internships Help Students, Health

Services (PA)

Health advocates. Students in the health advocatesprogram at the University of Minnesota helped track thespread of pandemic influenza across the campus and servedas a source of information and support in their residencehalls, apartment communities, fraternities, and sororities.Health advocates typically attend weekly classes at studenthealth services to learn how to respond to common healthissues in their residences and can earn credit through theSchool of Public Health. During the pandemic, healthadvocates received special training about H1N1 and campusresponse, were fitted with an N95 respirator and learned

26 HEALTH SERVICES | H1N1 & Higher Ed: Lessons Learned

Working with an epidemiologistwas very helpful. He was able toaddress questions right away. Anyschool that can attach itself to amedical center with an epidemiol-ogist should, because the publichealth department was totallystressed [during the pandemic].

Kristine Bordenave, MDMedical Director, Student Care Center

University of Chicago

TIP FROM THE FIELD

about the university’s recommendations for using them, andwere given a supply of surgical masks for students with flu-like symptoms and their roommates. They also:

• Learned when students with flu-like symptomsshould rest in their rooms and when flu-like symptomsnecessitated care at the health service

• Were trained to call the 24-hour nurse line to helpinform their decisions

• Were instructed on how students who were self-isolating could have meals delivered to their rooms

• Placed window clings in bathrooms to remind studentsto wash their hands

• Received specially equipped messenger bags with pre-made packages of thermometers and over-the-countermedications

• Were surveyed during weekly classes to determine howprevalent flu symptoms were in the residence halls andfraternities and sororities.

Student Health Advocates Also Address H1N1 (MN)

Facemask and N95 Respirator Recommendations (MN)

The 2009 H1N1 influenza pandemic showed that whencollege-age students are at high risk of developingcomplications during an influenza pandemic, universitiescan respond creatively and effectively. Strategies includestreamlining operations; sending students home whenpossible and encouraging well-supported self-isolation;collaborating with students, other medical professionals,and residential life services; and putting in place effectiveonline and phone protocols for triage and follow-up.

H1N1 & Higher Ed: Lessons Learned | HEALTH SERVICES 27

For details please see the Higher Education section of

CIDRAP’s Promising Practices site.Pennsylvania State University

Infection Control Internships Help Students, HealthServices (PA)

Phone Monitoring of Students With ILI (PA)

University of ChicagoQuality Improvement Redesign a Tool inPandemic Planning and Response (IL)

Students Serve as Peer Educators (IL)

University of Illinois Self-Isolation: The Family Home Option (IL)

University of IowaHealth Sciences Students Administer Vaccine onCampus (IA)

Resident Assistant Checklist for Assessing Students(IA)

University of MinnesotaFacemask and N95 Respirator Recommendations(MN)

Student Health Advocates Also Address H1N1 (MN)

University of Wisconsin-MadisonMHUB Communication Tool for Students, Staff, andFaculty (WI)

Telephone Triage and Treatment Protocol (WI)

Virtual EOC Is Campus Base of Operations (WI)��

��

��

��

��

��

Health Services Practices Online

Above, University of Michigan posters,

below, University of Minnesota stickers.

when you cough or sneeze – use a tissue or your upper sleeve, NOT your hands!

for 20 seconds using soap & warm water or use an alcohol-based hand cleaner

Two things you can do about theu…

Unviversity Health Service, Divisions of Student Affairs, www.uhs.umich.edu 2009

when you cough or sneeze – usNOT your hands!

e a tissue or your upper sleeve, when you cough or sneeze – use a tissue or your upper sleeve,

Unviversity Health S

for 20 seconds usingbased hand cleaner

Service, Divisions of Student Affairs, www.uhs

soap & warm water or use

s.umich.edu 2009

use an alcohol-

Lessons Learned Recap

• College-aged students were among the groups of people most at risk of developing complications from H1N1 infection. Universities became important sites for care, with campus health services playing a key role.

• Streamlining operations was a successful approach to maintain quality and effectiveness within the health service.

• Online and phone-based triage systems were used effectively to provide care information and referrals to patients.

• Prescribing self-isolation and home care can be a successful strategy if adequate support systems are put in place.

• Campus partners were available to provide additional staff support within the health service.

• Student leaders played an important role in providing information and care.

Actions and Challenges Ahead Include• Documenting and sharing health service successes.

• Ensuring adequate pandemic response supplies through stockpiling, which continues to be a challenge. In particular, having greater clarity about access to federally available antivirals at the campus level would be usefulfor many institutions.

• Encouraging additional federal dialogue on the use of personal protective equipment (PPE) during a pandemic toensure clear and consistent information at the local level. Availability of N95 respirators and fit-testing resources,including stockpiling considerations, was also cited as a challenge.

• Getting clarity about what some universities considered vague federal guidance about prescribing antiviral medications. Guidelines provided were cited by some as too restrictive, and lack of clarity led to frustration.

• Sharing lessons learned about the use of non-alcohol versus alcohol-based hand sanitizers, as well as the appropriate short- and long-term investments in those products, would be beneficial.

• Having public health partners play a greater role in educating family clinicians about the importance of reinforcingself-isolation recommendations.

THE POST-H1N1 LANDSCAPE: HEALTH SERVICES

28 HEALTH SERVICES | H1N1 & Higher Ed: Lessons Learned

eluged with data, news, guidance, andqueries during the 2009 H1N1 pan-demic, many Big 10+2 universities applied a simple strategy to solve thecomplex challenge of how best to communicate with their constituencies:Agree on one message and communicateit with one voice. Neither simple noreasy, of course, was the task of orches-

trating all the other variables, including deciding what to say,when and how often to communicate, what channels to use,and, in the case of electronic media, ensuring that the infra-structure was intact. Public affairs, news service, informationtechnology, health services, and emergency response profes-sionals, administrators, and student leaders formed partner-ships to ensure that people had the information they needed.

Universities developed strategies for communicating amongmembers of pandemic response teams; among members ofthe university community; and between the university andparents, public healthofficials, public serviceproviders, media, and thecommunity at large.

Universities made heavy useof online formats—Web sites,e-mail, social networkingtools, blogs, text messages,listservs, and electronicnewsletters. Face-to-face meetings, phone calls, videos, letters,white boards, cling signage, and posters also were put to use.Students even dressed in costume to spread the word aboutH1N1. This chapter addresses how universities managedcommunications. Following details about each lessonlearned are examples from the field.

Lessons learned during the pandemic response emphasizedthe following:

• Due to the rapidly changing, and sometimes conflicting,information from multiple sources, university respondershad to proactively coordinate and centralizecommunications.

• Universities relied heavily on online and e-mailcommunications as timely forums for informationexchange.

• Effective communications with college students meant aheavy emphasis on creativity.

LESSON: Coordinating communications was a high priorityEffective, timely, coordinated communications is a key part ofincident management. Even before the WHO made its officialdeclaration on Jun 11, 2009, teams were meeting face-to-faceand via conference call weekly, daily, or more. Respondersquickly recognized the need to be proactive in coordinatingand centralizing communications. The “one voice, onemessage” concept was widely emphasized and adopted.

CHAPTER 4

CommunicationsHow did universities harness the technology, the experts, and the creativityto harmonize messages about H1N1?

Effective communications

A key step in communicatingwas making information easy tofind and use. The university didthat in the virtual world byreorganizing its Web site toconsolidate all H1N1 informationin an easy-to-use format.Physically placing the informationin front of students on campuswas also a high priority.

Andrew BurchfieldManager of the Office of Emergency Preparedness

University of Michigan

TIP FROM THE FIELD

H1N1 & Higher Ed: Lessons Learned | COMMUNICATIONS 29

One voice,

one message

mattered most

KEY TAKEAWAY

Universities addressed communications from organizational,technical, and collaborative perspectives. The University ofWisconsin-Madison established its EOC and used an e-mailplatform called MHUB to manage communications. AtPurdue University, emergency preparedness staff sent dailybulleted items in a situation report to the pandemicpreparedness committee. The University of Minnesotaformed a communications group with representation fromUniversity Relations, health services, the Academic HealthCenter’s Office of Emergency Response, and the School ofPublic Health, and shared information via an e-mail listservand met by phone every Tuesday. The Ohio StateUniversity director of emergency management and safetydirector opened a “unified office” to share information andunify messaging.

The Internet quickly became the hub for information andupdates at universities. Some universities also used theInternet for online triage and for scheduling clinic visits andvaccinations. With so many Web sites and pages at eachuniversity, the possibility existed for conflicting informationto appear online. Many universities made it a priority tocentralize electronic information to improve accuracy andclarity of information. The University of Minnesota placedan icon on all pandemic-related communications that, whenclicked, took the user to the main H1N1 page. The Universityof Michigan pulled all materials into one section on its site.

Coordinating messages with public health authorities wasvaluable, though not always feasible. The University ofMinnesota helped to distribute an open letter to athleticdirectors and coaches from the state epidemiologist toreinforce the importance of athletes staying home when sick.The University of Wisconsin-Madison publishedinformation about H1N1 before the Wisconsin Department ofHealth Services did, because illness appeared on campus andspread quickly in spring 2009. Nonetheless, the universityneeded to align its communications with the state’sthroughout the pandemic, because the university employedapproximately half of the state workers. The state healthdepartment also had authority over some university activities,such as cancelation of public gatherings. Universitiesemphasized the importance of harmonizing key messageswith public health partners.

EXAMPLES FROM THE FIELDExperts vet information. Given the rapid pace of changeand the serious consequences of misinformation, being firstand being right were key elements of H1N1 communications.University communications personnel crafted messages butvetted all information for accuracy through health servicesstaff at Indiana University and the University of Iowabefore publication. University of Wisconsin-Madisoncommunications were mainly handled by a communicationscorps that included a police lieutenant and staff fromuniversity and health services communications.

Trusted sources present information. Media interest inhow universities were managing the pandemic spiked duringperiods of peak illness, when vaccine became available, andwhen long lines were a possibility. Purdue University chose asenior communications professional from its news serviceunit to handle media inquiries. Many universities consistentlyrelied on one trusted spokesperson, or a small team, tocommunicate with the media about pandemic influenza.

Audience-specific messaging can be useful. Certainaudiences, such as parents, want very specific information ina public health emergency. To help address such concerns, aUniversity of Illinois health service physician wrote letters toparents of Illinois students. The writer had special insight,because he too was the parent of an Illinois student.

Communications With Parents (IL)

LESSON: Universities relied heavily on online and e-mail communications Technology played a key role in pandemic communications.Universities used a variety of means to disseminate messageson topics ranging from vaccination clinics to hand hygieneand absenteeism to self-isolation. Online communicationswere an important way to collect and answer questions.Forums for questions ranged from using special e-mailaddresses and adding a blog to a main Web site to postanswers to frequently asked questions. One university createda newsletter that it credits with keeping queries down.

The frequency with which universities updated their H1N1Web sites, sent out new messages, and responded toquestions depended on myriad factors. The University ofMinnesota, which committed to frequent Web site updates,found that traffic to the site was lower than expected unlessmessages went out that prompted people to visit. Too-frequent e-mails, however, created “message fatigue,” so theuniversity scaled back to one message a week—unlesschanging conditions required the community to be updated.

EXAMPLE FROM THE FIELDCreating a communications hub. The University of

Wisconsin-Madison used a communications focal pointcalled MHUB as a major tool for fielding questions andcommunicating with students, faculty, and departments. Staffposted the MHUB e-mail address as a link on the main Website and health services Web site. Students and universitypersonnel sent questions to the MHUB e-mail account. Thataccount was monitored by a member of the campus policedepartment, which oversees emergency management oncampus. The officer would answer them if they pertained toemergency response on campus or forward them to theappropriate department. Police department staff maintaineda database of these questions and kept questions aboutmedical issues, housing, grades, and other topics in separatelogs to track student and staff concerns.

30 COMMUNICATIONS | H1N1 & Higher Ed: Lessons Learned

MHUB ensured that a quick, responsive flow ofcommunication within and outside UW existed during eventhe busiest days of the pandemic. During spring 2009, theMHUB account needed to be checked every half hour, buteventually staff scaled back to checking for messages every 2hours. UWPD forwarded answers in one business day,although e-mails concerning flu symptoms were forwarded asurgent to health services.

MHUB Communication Tool for Students, Staff,

and Faculty (WI)

LESSON: Creativity is a key to working withcollege studentsUniversities found creative ways to reach college studentswith H1N1information. Their diverse approaches—fromhigh-tech virtual chats to one-on-one conversations—underscore the value of using multiple modes ofcommunication.

Podcasts, text messaging, and platforms such as Facebook,Twitter, and Blogspot were not widely used when Big 10+2universities began pandemic planning. But adoption of socialnetworking had exploded by the time the 2009 H1N1influenza pandemic began, and universities capitalized onthat growing popularity. The Ohio State University added ablog to its main H1N1 Web site to answer student questionsand update information in a timely way.

High-tech approaches in many cases were buttressed by shoe-leather conversations, often featuring students reaching outto their peers with important health information.

EXAMPLES FROM THE FIELDVolunteers with a Red Cross student chapter at Purdue

University climbed on buses to hand out more than 5,000informational fliers, as well as hand sanitizer, to CityBuspassengers on routes frequented by students.

American Red Cross Student Chapter H1N1 Project (IN)

Student interns in infection control at Pennsylvania StateUniversity took turns donning a homemade “flu bug” outfitand handing out fliers about prevention to their peers.

Infection Control Internships Help Students, Health

Services (PA)

Student health advocates at the University of Minnesotaand others at the University of Michigan stuck mirror clingsin residence halls and other places to spread hygiene tips.

Communications Outreach Ranges From Mirror Clings to

E-mails (MI)

Student Health Advocates Also Address H1N1 (MN)

Communications is a demanding aspect of emergencyresponse that depends on many factors, including:

• Having the right subject matter experts to vet messages

• Harmonizing messages with public health partnerswithin and outside of the university whenever possible

• Understanding and using the right technologies toreach people

• Recognizing that different audiences may respondbetter to different messages

• Using creativity to reach students, who have manycompeting demands on their attention.

Although the messages will change from one emergency toanother and sometimes from one day to another, thetechnological infrastructure and human connections thatenhanced H1N1 communications will serve universitieswell for many other emergencies.

For details please see the Higher Education section of

CIDRAP’s Promising Practices site.Minnesota Department of Health

Open Letter to Athletic Directors and Coaches (MN)

Pennsylvania State UniversityInfection Control Internships Help Students, HealthServices (PA)

Purdue University (and the Purdue Chapter of theAmerican Red Cross)

American Red Cross Student Chapter H1N1 Project (IN)

University of ChicagoMalcolm Gladwell Theory Employed in VaccineDistribution (IL)

University of Illinois Communications With Parents (IL)

University of MichiganCommunications Outreach Ranges From MirrorClings to E-mails (MI)

University of MinnesotaStudent Health Advocates Also Address H1N1 (MN)

University of Wisconsin-MadisonMHUB Communication Tool for Students, Staff, and Faculty (WI)

Telephone Triage and Treatment Protocol (WI)

Virtual EOC Is Campus Base of Operations (WI)��

��

��

��

��

Communication Practices Online

H1N1 & Higher Ed: Lessons Learned | COMMUNICATIONS 31

Lessons Learned Recap

• Due to the rapidly changing, and sometimes conflicting, information from multiple sources, university respondershad to proactively coordinate and centralize communications.

• Universities relied heavily on online and e-mail communications as timely forums for information exchange.

• Effective communication with college students meant a heavy emphasis on creativity.

Actions and Challenges Ahead Include• Documenting and sharing communication successes from this pandemic.

• Identifying additional creative ways to communicate with parents (a need reported by some institutions).

• Expanding and leveraging public health partnerships to harmonize communications could further save time andresources.

THE POST-H1N1 LANDSCAPE: COMMUNICATIONS

32 COMMUNICATIONS | H1N1 & Higher Ed: Lessons Learned

ifficulty getting enough H1N1 vaccineto immunize students, faculty, and staffwhen they were ready and willingpresented Big 10+2 universities withtough logistical and public relationschallenges. It also showcased theirability to improvise creative solutionsin the midst of uncertainty. Against anational media backdrop of long lines

of frustrated people waiting for vaccine, Big 10+2 universitiessurprised even themselves with the efficiency and success oftheir mass vaccination clinics. This chapter examines howuniversities dealt with vaccine distribution, includingplanning and operating mass vaccination clinics for students,faculty, and staff. Following each lesson are examples fromthe field.

Lessons learned during the pandemic response emphasizedthe following:

• Vaccine distribution to universities was unpredictable,which made planning and implementation of distributionefforts on campus very challenging.

• Past seasonal influenza vaccination experiences andbioterrorism response planning with public healthpartners provided templates for H1N1 vaccine distribution.

• Due to the challenges of unpredictable vaccine availability,creative strategies were developed rapidly using online orphone-based systems.

• Creative approaches were also used to meet significantstaffing needs.

LESSON: Vaccine supply distribution wasunpredictable, making planning andimplementation efforts challengingAs vaccine became available, state and local public healthauthorities were charged with first vaccinating groups athighest risk of developing complications. But severallogistical complications arose: (1) doses arrived later thanexpected, (2) the quantities were lower than estimated, and(3) subsequent deliveries were erratic. In addition, shipmentsof vaccine in nasal spray form arrived before the injectable

vaccine did. Generally, thepublic is less familiar andless comfortable with thenasal spray vaccine (madewith a live, thoughweakened, virus) than theinjectable kind (made witha “killed” virus). The liveattenuated influenzavaccine (LAIV) spray isn’t always appropriate for certain high-risk groups, and worries about the LAIV presented the Big10+2 with yet another challenge.

Thus, universities had to plan, coordinate, and staff massvaccine clinics when they didn’t know for certain when they’dget shipments, how much vaccine they’d receive, and whatform of product they would get.

LESSON: Past experiences and bioterrorismresponse planning provided useful templatesUniversities needed as much flexibility as possible to workwith the shifting variables and still immunize as manypeople as they could while the interest in vaccine was high.Many offered vaccine in non-clinic settings. Some universitiesprovided vaccine only to students; others made it available tostudents, faculty, staff, and dependents. Still others workedwith local public health authorities to immunize others intheir communities. Universities hosted mass walk-in clinicsand drew on successful seasonal-flu strategies.

EXAMPLES FROM THE FIELDTaking vaccine to students. The medical director of the

Student Care Center (SCC) at the University of Chicago usedher team’s success in improving seasonal influenza vaccinerates as a springboard for organizing H1N1 vaccine efforts.Using “the power of context” approach described in MalcolmGladwell’s book, The Tipping Point: How Little Things CanMake a Big Difference, the team opted several years ago tomeet students on their own turf. The goal was to make it asconvenient as possible. They selected vaccination sites thatalready had considerable student foot traffic. Promotionalmaterials listed locations and included maps. During clinics,maps, signs, and arrows directed students to the sites.

H1N1 & Higher Ed: Lessons Learned | VACC INE DISTR IBUTION 33

CHAPTER 5

VaccineDistributionWith virtually no control over vaccine supplies, how did Big 10+2 universitiessuccessfully immunize thousands of people?

Coping with

uncertainty was

key to success

KEY TAKEAWAY

Seasonal vaccination rates more than doubled the first yearthe SCC tried the approach. At the peak of the H1N1pandemic, the clinicians were vaccinating approximately 25%of the total student population of 15,000.

Malcolm Gladwell Theory Employed in Vaccine

Distribution (IL)

The right place at the right time. The executive directorof the health center at Indiana University also consideredstudent habits when he selected the time and venue of H1N1vaccine clinics. Plenty of parking was one criterion, andtiming the clinics when students were most likely to beavailable was another. Clinics were held in the lobby of thebasketball center, from 11 am to 7 pm, after classes startedbut before evening activities.

Perfecting points of dispensing. The directors of thestudent health center at Purdue University and theTippecanoe County Health Department applied the lessonsfrom a previous mass clinic collaboration related toantibiotic distribution in the event of a bioterrorism attack tostreamline H1N1 vaccine clinics. Purdue developed andtested specific floor plans for designated Points of Dispensing(PODs) on campus. Purdue’s approach to mass vaccinationclinics changed to minimize wait times and enhanceefficiency of the university-county–run clinics. Among thelessons they learned were:

• Site selection is critical. The facility needs to be large andhave ample parking. Don’t skimp on staff. A clinic manageris needed to carefully organize the POD, assignresponsibilities, and coordinate with the healthdepartment the supplies needed. Purdue hired a graduatestudent as the clinic manager. Nursing students helpedadminister vaccine. For optimal movement through thePOD, vaccine stations need to be overstaffed.

• Ensuring optimal flow. POD layout must be consideredto move people quickly. Purdue set up six stations andprocessed 700 to 800 people an hour. The turnaround timewhen everything was set up properly was no more than aminute. Ushers directed pre-registered people who hadforms completed to vaccinators; walk-ins would sit at atable to fill out paperwork before getting a vaccine. Anylines that formed were reduced within 30 minutes.Another way Purdue worked to prevent lines was to havethe clinic ready 30 minutes earlier than scheduled. If a linebegan to form, the clinic would open early.

Mass Clinic Approach Evolved to Meet Needs (IN)

LESSON: New strategies were developedrapidly to use online or phone systemsOnline scheduling gave universities some control over thenumber of people they could vaccinate and helped themidentify who should receive the type of vaccine they had onhand. One university customized telephone technology tostreamline clinic scheduling and communications.

Universities that booked vaccine appointments online ensured24-hour student access. The advantage for universities wascontrolling who came to clinics and when, thus compensatingfor unpredictable vaccine supplies. Online booking also some-times included paperwork for students to download and signbefore they came to the clinic, which helped speed the process.

EXAMPLES FROM THE FIELD‘Just-in-time’ registration. Owing to uncertainties about

how much vaccine it would receive, Indiana Universitydecided to limit clinics to 3 days a week and offer 1,200

Purdue University

Overstaff vaccine stations. Ican’t overemphasize that point.You want to hear a giant suckingsound when the nurses’ stationsopen. If you do have a line, utilizeit for filling out paperwork.

Mike Bohlin, MDDirector, Tippecanoe County Health Department, Indiana

NOTES FROM THE FIELD

How to Avoid Long Lines at Vaccine Clinics• Register people online or using an automated phone

service

• Encourage people to wear short-sleeve shirts

• Be ready to open a half hour earlier than the scheduledtime

• Overstaff clinics

• Involve students in all facets

• Use good signage, with arrows pointing to the clinic

• Make forms available online and encourage people tofill them out before they arrive

• Don’t administer seasonal and H1N1 vaccine at thesame time

TIP FROM THE FIELD

34 VACC INE DISTR IBUTION | H1N1 & Higher Ed: Lessons Learned

appointments a day using a secure online system. Over thecourse of the clinics, more than 7,000 people were vaccinated.Planners said the following factors led to their success:

• Rolling registration. The university developed a secureonline registration system for faculty, staff, and students.Once appointments for one day were filled, the systemautomatically began filling the next day’s slots.

• Pre-vaccine paperwork. Registrants were instructed todownload materials to complete before the appointment.

• Spreading the word. The university used every channelavailable—Facebook, Twitter, e-mails from a dean,television ads—to announce clinics.

• Injections-only policy. The university declined nasal-sprayvaccine. That decision eliminated time that otherwisewould have been spent on addressing safety concernsabout the LAIV, a spokesperson said. The university had acollaborative agreement with pediatricians to take thedeclined LAIV doses.

An off-the-shelf option. Flexibility was very critical toMichigan State University (MSU) when it selectedSurveyMonkey, a secure, customizable online tool, to registerstudents for H1N1 vaccination appointments. The softwareoffered the flexibility MSU needed to accommodate changingeligibility guidelines and spotty delivery of supplies.

Customizing a telephone system. The Ohio StateUniversity found that building and launching an onlinesystem would take a month. An alternative approach was touse a phoned-based scheduling system. That system was builtin 2 days, tested over a weekend, launched, and proved to behighly efficient and successful.

Automated Clinic Registry Simplifies Vaccine Clinics (OH)

Building blocks. After several walk-in vaccination clinicstook place at the University of Minnesota, plannersidentified a need to regulate client flow and reduce waittimes. They shifted to an online system that allowed clientsto register for a 15-minute block of time. Within each timeblock, clients were vaccinated on a first-come, first-servedbasis. The system enhanced clinic operations by shorteningwait times, promoting a steady and predictable flow ofpatients, maximizing resources and vaccine delivered, andultimately increasing the number of vaccinations provided.Use of the system also resulted in less stress on clients, as wellas nurses and other clinic staff.

The Minnesota Department of Health awarded Public HealthEmergency Response (PHER) IV funds to the university toexpand and enhance the online scheduling system. Oncecompleted, this new system will be used to support seasonalinfluenza vaccine campaigns, as well as standing ready forfuture pandemic response.

Getting Immunized: The ‘5-Minute’ ClinicBig 10+2 universities vaccinated thousands of students,faculty, staff, dependents, and community membersquickly while working with many variables beyond theircontrol. Generally, they estimated they were able to getpeople through the clinic in about 5 minutes, and waitingtime typically was used for paperwork.

TIP FROM THE FIELD

H1N1 & Higher Ed: Lessons Learned | VACC INE DISTR IBUTION 35

Universities that booked vaccine appointments online

ensured 24-hour student access. The advantage for

universities was controling who came to clinics and

when, thus compensating for unpredictable vaccine

supplies. Online booking also sometimes included

paperwork for students to download and sign before

coming to the clinic, which helped speed the process.

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LESSON: Creative approaches were used to meet staffing needs The unpredictability of vaccine supply complicated efforts toarrange vaccine clinics, but getting and scheduling sufficientstaff on short notice were additional challenges. Big 10+2universities rallied help in creative ways, often calling on a widerange of people with interest in medicine and health sciences.Several universities noted how instrumental students were tothe success of their vaccination efforts. Students served aspromoters, greeters, paperwork wranglers, and vaccinators. Thedirector of student health services at one university said: “Wecouldn’t have done it without them.” Students also helpedspread the word about vaccine availability. At one university,the waiting room of a clinic filled 10 minutes after theuniversity sent an e-mail announcing vaccine was available, andmany students texted friends to meet them at the health center.

EXAMPLES FROM THE FIELDHealth sciences students pitch in. When H1N1 vaccine

began to trickle in to the University of Iowa (UI) campus

in fall 2009, the Student Health Service relied on a familiarresource to help vaccinate students—UI health sciencesstudents. Administering vaccine under staff supervision,students formed a strong clinical and logistical foundation ofthe H1N1 vaccination campaign. UI had precedence forinvolving students. Nursing students have always helped withseasonal influenza vaccination. Pharmacy students alsobecame involved in H1N1 clinics. Nursing and pharmacystudents also helped with community vaccination clinicssponsored by the Johnson County Public Health departmentand the Johnson County Visiting Nurse Association.

Health Sciences Students Administer Vaccine on Campus (IA)

Using help from the Medical Reserve Corps. TheMedical Reserve Corps (MRC) at the University ofMinnesota comprises some 900 students, staff, and facultyfrom the Academic Health Center and Boynton HealthService. Its mission is to prepare for and respond to large-scalecampus, local, state, or national emergencies efficiently,providing unique educational and experiential opportunitiesfor students, staff, and faculty. Since its creation in 2004, theMRC has aided emergency response and public healthinitiatives on campus and in the broader community. So itwas not unusual when the campus health service requestedMRC support for its H1N1 mass vaccination clinics. Morethan 100 MRC members assisted with registration, screening,ushering, supply support, and injections. MRC membershelped streamline clinic operations and were described asqualified, competent, and flexible.

Medical Reserve Corps Assists With Vaccination Clinics (MN)

Responding to the H1N1 influenza pandemic requiredconstantly adapting to changing circumstances andbalancing shifting variables such as vaccine supply anddemand. Leveraging past experience, customizingtelephone or computer technologies, and finding creativestaffing solutions helped Big 10+2 universities vaccinatecampus community members.

36 VACC INE DISTR IBUTION | H1N1 & Higher Ed: Lessons Learned

The use of online blockappointments was extremelysuccessful. Public health partnershave approached us with aninterest in adopting a similarmodel.

Ed Ehlinger, MD, MSPHDirector and Chief Health Officer, Boynton Health Service

University of Minnesota

TIP FROM THE FIELD

Students served as promoters, greeters,

paperwork wranglers, and vaccinators.

The director of student health services at

one university said, “We couldn’t have done

it without them.” Students also spread the

word about vaccine availability.

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The Ohio State University

An Automated Phone System forVaccine Registration

Planners at The Ohio State University developed a phonevaccination registration system that registered thousandsof students and staff for their vaccinations.

How it was developed• Planners developed a flow chart indicating how callers

should be routed. The system was built in 2 days andtested over a weekend.

• A caller would first self-identify as a student, faculty, or staff. The phone system then asked for the caller’suniversity identification number, to pull up that caller’se-mail address.

• Next, the phone system asked the caller’s vaccinepriority group(s).

• The system sent an automatic registration e-mail tothat caller, and university officials could trackregistration in daily reports.

How it worked• The first round of calls—to register people—occurred

about 3 weeks before vaccine arrived.

• When planners received vaccine, the automated system e-mailed the first batch of registrants in high-priority groups.

• Pre-registered people in high-priority groups were toldthat vaccine would be available at certain times andlocations and then asked to select the clinic time thatbest fit their schedules.

Results• Between 3,500 and 5,500 students, faculty, and staff

registered using the automated registration system.

• The system functioned well.

• The average wait-time with full staffing was about 5 minutes.

TOOLS FROM THE FIELD

For details please see the Higher Education section of

CIDRAP’s Promising Practices site.Purdue University

Mass Clinic Approach Evolved to Meet Needs (IN)

Purdue University (and the Purdue Chapter of theAmerican Red Cross)

American Red Cross Student Chapter H1N1 Project (IN)

The Ohio State UniversityAutomated Clinic Registry Simplifies Vaccine Clinics (OH)

University of ChicagoMalcolm Gladwell Theory Employed in VaccineDistribution (IL)

Quality Improvement Redesign a Tool in PandemicPlanning and Response (IL)

University of IowaHealth Sciences Students Administer Vaccine onCampus (IA)

University of MinnesotaMedical Reserve Corps Assists With VaccinationClinics (MN)

Online Scheduling System for Vaccinations (MN)��

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Vaccine DistributionPractices Online

H1N1 & Higher Ed: Lessons Learned | VACC INE DISTR IBUTION 37

Lessons Learned Recap

• Vaccine distribution to universities was unpredictable, which made planning and implementation of distributionefforts on campus very challenging.

• Past seasonal influenza vaccination experiences and bioterrorism response planning with public health partnersprovided useful templates for H1N1 vaccine distribution.

• Due to the challenges of unpredictable vaccine availability, creative strategies were developed rapidly using onlineor phone-based systems.

• Creative approaches were also used to meet significant staffing needs.

Actions and Challenges Ahead Include• Documenting and formalizing the new and modified vaccine distribution systems that were used successfully in

response to H1N1.

• Considering use of pre-distribution education on LAIV and working with public health partners to increase aware-ness of LAIV in the community.

THE POST-H1N1 LANDSCAPE: VACCINE DISTRIBUTION

38 VACC INE DISTR IBUTION | H1N1 & Higher Ed: Lessons Learned

aculty at most Big 10+2 universities wereeither encouraged to relax theirattendance expectations and rules or werenotified by provosts and deans thatexisting policies were being formallysuspended during the 2009 H1N1influenza pandemic. The goal: Ensurethat students (and faculty) could followthrough on public health recommend-

ations to self-isolate while they were infectious and recovering.But asking faculty to change the requirement for a student toproduce a doctor’s note to have an absence excused createdconflict that often required intervention by provosts and deans.Historically, the appropriateness of the doctor’s note has been asource of disagreement between academic and health servicescolleagues. During the pandemic, however, the note policy wasa specific barrier to a public health recommendation for thosewith influenza-like symptoms to self-isolate.

Before H1N1,universities looked atways to teachremotely ifabsenteeism requiredthem to shut down.They also knew thatcancelling study-abroad programs wasa possibility. As itturned out, neitherstep was needed, but universities did cancel trips to Mexico.This chapter addresses teaching issues. Following each lessonare examples from the field.

Lessons learned during the pandemic response emphasizedthe following:

• Pandemic influenza response plans need specific proceduresto address the effects on study-abroad programs

• Teaching policies and individual faculty practices playan important role in supporting self-isolation strategies forstudents.

• Although distance learning techniques were notrequired, hindrances to their successful implementationwere highlighted during pre-pandemic planning.

LESSON: Response plans need specificprocedures for study-abroad programsThe fast global spread of the pandemic had an impact ontravel-abroad programs. Universities wound up cancelingspring trips to Mexico, where reports first emerged of seriousH1N1 illness. During the fall, the US Department of Stateissued alerts about extreme quarantine measures in China.Passenger screening varied from country to country.Universities, however, did not report major problems withstudy-abroad programs but noted strong cooperation withcolleagues in these programs. H1N1 underscored the need tobe prepared for a pandemic to emerge at any time from anyglobal region.

LESSON: Teaching policies and faculty playan important role in students’ self-isolationFew issues generated as much internal dismay during thepandemic as excusing student absences for flu-like illness.The CDC made self-isolating a key tenet of its guidance,encouraging people with flu-like symptoms not to return toclasses until 24 hours after being fever-free without fever-reducing medication. A full recovery could take 3 to 7 days. If complications such as pneumonia developed, studentscould be out longer.

To reduce virus transmission and encourage full recovery,most universities opted to embrace CDC guidelines andpromote self-isolation, but this was only the first step. Thestrategy tended to be unpopular with many faculty membersand created friction on some campuses. To complicatematters, in regions where the fall wave of illness peaked byearly November, the timing coincided with end-of-semesterdeadlines and fast-approaching exams. The practical questionuniversities faced was how to loosen faculty grip on the long-held tradition of deciding which absences to excuse.

H1N1 & Higher Ed: Lessons Learned | TEACH ING 39

CHAPTER 6

TeachingHow did Big 10+2 universities help ill students stay away from classrooms torecover while preserving academic expectations and requirements?

Supportive

leadership made

possible short-term

solutions

KEY TAKEAWAY

With the exception of the University of Wisconsin-Madison, Big 10+2 institutions had some form of studentattendance policy that required proof of illness, andunexcused absences came with academic penalties thataffected students’ grades. With limited capacity of healthservices to see every sick student and universities’ heavyreliance on online and phone triage, the chances of a studentsecuring a doctor’s note for flu-like illness during thepandemic were slim to none. Students who worried aboutacademic penalties were known to show up for class sick orreturn to busy clinics to get notes.

Universities identified the support of provosts and deans askey to the success of a self-isolation strategy. Universitieshighlighted the value of involving those key leaders duringplanning and the importance of their willingness tocommunicate about relaxing attendance policies orintervening to resolve conflict when necessary.

EXAMPLES FROM THE FIELDRequesting faculty help. Some of the Big 10+2

universities simply requested more flexibility from facultyduring the pandemic—and got it. An Aug 11, 2009, letterfrom the provost at Purdue University said:

“Our students are in an age group that has been mostaffected by Influenza A H1N1 (ages 5-24). Also at highrisk are pregnant women and individuals with chronicailments such as asthma. Because a high proportion of thePurdue family is in the high risk group, we must beespecially vigilant.”

The provost went on to suggest that faculty be sure classes andstudents were “storm-ready,” including doing the following:

• Consider adjusting attendance policies to preventpenalizing ill students for “doing the right thing and notattending class”

• Develop a method of mass communication so theycould alert students about any cancellation of classes or assignments

• Make plans to help students get caught up upon theirreturn to class

• Talk with students about not coming to class whilethey have a fever or until they recover

• Prepare personally

Purdue also provided a link to faculty online resources onhow to respond to a pandemic.

Adjusting the policy. Others institutions, such as theUniversity of Iowa, sought middle ground by crafting asimple online form for sick students to fill in and submitelectronically. The university made clear to faculty andstudents that grades were not to be affected by absences and

that students were responsible for completing requirements.Online Class Absence Form for Flu-Like Illness (IA)

Suspending policies. Pennsylvania State Universityformally suspended its absence policy, while The Ohio StateUniversity allowed students to submit a pandemic-specificexcused absence form that could be used once, thus reducingthe possibility that anyone could take advantage of the morelenient policy. Interestingly, some universities reported thatstudents were more likely to come to class sick for fear ofpenalties than to abuse the policies.

In the end, planners from several universities suggested thatif the CDC targeted messages to faculty about the importanceof students self-isolating during a pandemic, then the strategywould be easier to put into practice.

LESSON: Planning revealed hindrances to distance learning Although the Big 10+2 universities did not have to shuttercampuses, planners knew it was a possibility if absenteeismreached high levels. Some universities had encouraged facultyto explore distancing learning options as a way to ensureeducation continuity.

Faculty and COOPs. At the University of Wisconsin-Madison (which had a no-doctor-note policy before thepandemic), departments were asked to develop models ofsocial distancing and ways to supplement teaching plans andwere invited to attend an educational forum on teachingwhen social distancing is required. Faculty were required to

Supporting Student Self-Isolation

Dealing With Attendance PoliciesWhen confronted with faculty objections to relaxingattendance policies, universities found they were betterable to support self-isolation if:

• Provosts and deans supported the strategy andcommunicated that support effectively

• Decision-makers officially suspended existingattendance policies, including the requirement of adoctor’s note to excuse ILI-related absences.

• Media were covering the pandemic, making the threatappear real and pointing out that young people wereat higher risk of developing complications

• They could effectively highlight CDC recommendations

NOTES FROM THE FIELD

40 TEACH ING | H1N1 & Higher Ed: Lessons Learned

H1N1 & Higher Ed: Lessons Learned | TEACH ING 41

identify their most critical courses and to write COOP plansdetailing how they would proceed if classes were canceledduring the H1N1 pandemic or due to any future disaster.Those plans were reviewed according to criteria supplied bythe provost’s office, the health services director, and UW’senrollment management office. Plans were tracked andreported to the committee charged with monitoring progress.As part of their plans, faculty members were also asked totake a generous approach to allowing ill students to make upwork.

Information technology services. With so much ridingon the ability of faculty and students to interact remotely andto receive updated information, information technologyleaders have a role ensuring that Web sites can be updatedquickly and helping evaluate or design distance learningpossibilities. In addition, information technology helpeduniversities schedule vaccination clinics and track illstudents, emphasizing the broad importance of those staff asstakeholders in response.

Self-isolation during a flu-like illness was a key tenet oflimiting the spread of the pandemic. Encouraging studentsto stay home or in their room while ill meant relaxingclass attendance requirements. Some universities formallysuspended attendance policies, while others allowedstudents to fill out online absence forms. Future efforts arelikely to address additional issues off-campus, such asstudy-abroad and distance learning issues.

For details please see the Higher Education section of

CIDRAP’s Promising Practices site.University of Iowa

Online Class Absence Form for Flu-Like Illness (IA)�

Teaching Practices Online

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Lessons Learned Recap

• Pandemic influenza response plans need specific procedures to address the effects on study-abroad programs.

• Teaching policies and individual faculty practices play an important role in supporting self-isolation strategies for students.

• Although distance learning techniques were not required, hindrances to their successful implementation werehighlighted during pre-pandemic planning.

Actions and Challenges Ahead Include• Requesting that CDC consider the creation of targeted communications to faculty on the need to modify policies

and practices when self-isolation strategies are used to address infectious disease outbreaks.

• Reviewing and further developing (as needed) models for addressing existing self-isolation policies and the role of faculty in providing information and support to students.

• Documenting procedures used to make policy modifications, either formally or informally, so that modificationscan be made rapidly in the future.

• Further developing distance learning capabilities in some institutions, including teaching strategies, facultypreparation, and information technology infrastructure.

THE POST-H1N1 LANDSCAPE: TEACHING

42 TEACH ING | H1N1 & Higher Ed: Lessons Learned

uman resources (HR) issues surfacedquickly when the 2009 H1N1influenza pandemic arrived on Big10+2 campuses, and more than a yearlater, a few still remain unresolved.Universities addressed how torespond to employee questions andconcerns, how to apply sick-leave andpay policies during a pandemic, and

what kind of HR guidance was needed. They also worked todetermine how to ensure sick employees stayed away fromthe workplace, how to protect healthy employees until avaccine became available, and how to staff for surges indemand for certain services. This chapter examines howinstitutions addressed human resources. Following eachlesson learned are examples from the field.

Lessons learned during the pandemic response emphasizedthe following:

• Clear and timely information was needed for HRprofessionals, department heads, supervisors, andemployees to effectively implement public healthrecommendations in the workplace.

• Pandemic response efforts highlighted the importance ofcontinuity of operations planning, including thedesignation of essential personnel.

LESSON: Personnel need clear and timely informationWhile pivoting to respond to the threat of the H1N1pandemic, HR staff had to factor in the complex hierarchy ofemployees at Big 10+2 universities (tenured and non-tenuredfaculty, salaried staff, hourly workers, part-time andtemporary staff, student workers, and employees workingunder collective bargaining agreements) and their differingmix of time-away-from-work benefits. Meanwhile, state andfederal employment laws and standards still had to be met.But even some of these—the Family Medical Leave Act(FMLA) and Americans with Disabilities Act (ADA), forexample—required review by government officials who thenpublished pandemic-specific guidance that HR professionalshad to monitor, interpret, communicate, and apply.

With a few exceptions,most Big 10+2universities did not craftpandemic-specific sick-leave and sick-paypolicies. One of the mostonerous HR challengeswas how to achieve theCDC recommendationthat people who had symptoms of flu-like illness stay homeuntil fever-free for 24 hours without the aid of fever-reducingmedications. Encouraging sick employees to stay home runscounter to many work and societal norms.

In addition, compensation policies, in particular, became athorny issue. For example, for some employees whose paydepended on their presence at work and who don’t receivepaid sick leave, staying home was not financially feasible. Themany university job categories and variety of leave benefitsmade trying to produce one-size-fits-all pandemic sick-leaveand pay policies too unwieldy for many universities.

Guidelines, targeted communications, and, in somesituations, new policies were created to promote sharedunderstanding, support uniform practices, and answeremployee questions.

In the end, relaxing existing attendance policies rather thanrevamping them became the default solution for most of theBig 10+2 universities. One of the first campuses to have aconfirmed case of H1N1 infection, the University ofChicago opted by May not to penalize employees who stayedhome with flu-like symptoms. The University of Wisconsin-Madison revised attendance policies to relax requirementsfor medical excuses and to allow for telecommuting ifpossible. Pennsylvania State University expanded familysick-leave policy in general to encourage employees to stayhome when ill.

EXAMPLES FROM THE FIELDCampus-level guidelines for department-level

decision making. As part of its response to the H1N1pandemic, the University of Illinois Infectious Disease WorkGroup, comprising representatives from across the university,

H1N1 & Higher Ed: Lessons Learned | HUMAN RESOURCES 43

CHAPTER 7

Human ResourcesHow did Big 10+2 universities work to protect a diverse workforce within thecomplex regulatory environment of human resources?

Relaxing policies

didn’t reguire

revoking them

KEY TAKEAWAY

tried to articulate how university employers should handleemployee illness in a pandemic. Bumping up against a wallof variables, the group opted instead to provide guidance thatindividual units and departments could use to make theirown decisions. The guidelines address topics such as whetheremployers could send sick employees home, how FMLAapplies, and whether an employer could cancel anemployee’s vacation time in a staff shortage. Most Illinoisemployees are unionized, so before posting the guidance, anHR representative sat down with each union to hearimmediate feedback and ensure buy-in.

HR Guidance Development (IL)

Campus-level policy. The University of Minnesotadeveloped a policy that outlines how the president ordesignee may determine circumstances that would necessitatethe declaration of a University State of Emergency, or changein standard operations, either to limit exposure using “socialdistancing,” or as a result of extremely high rates ofabsenteeism related to pandemic influenza. The policy wasdrafted by HR leaders on campus in consultation withacademic health partners after reviewing draft policiescreated elsewhere. Although a work in progress since 2007,the policy was formally adopted based upon concerns aboutthe 2009 H1N1 pandemic. In the end, there was no need toimplement the policy; however, it provided information toemployees on the intended approach should a more severepandemic affect the campus.

State of Emergency Policy (MN)

Anticipating employee questions. Early in thepandemic, anticipating that there may be questions about theuse of personal protective equipment (PPE) in the workplace(particularly access to university and government-heldstockpiles), University of Minnesota administrators chargedan ad hoc task force to develop PPE recommendations. Therecommendations were made available to HR professionalsand were used to respond to employee inquiries. In the end,employees did not raise serious concerns about this issue;however, the recommendations will be revised as needed toaddress PPE recommendation during future pandemics orother infectious disease emergencies.

Facemask and N95 Respirator Recommendations (MN)

LESSON: Importance of continuity of operations planningAs large employers with sizeable and complex workplaces, Big10+2 universities generally develop continuity of operationsplans (COOPs) as part of overall preparedness planning. Butplanning for an influenza pandemic requires a dual approach:(1) ensuring operational coverage when a high proportion ofthe workforce is absent, and (2) addressing situations forwhich social distancing measures severely limit access to thecampus.

Full implementation of COOP plans was not needed forH1N1. However, university planners noted the importance ofcontinued work on those plans and the challenges inherentin determining essential and non-essential personnel acrossthe entire campus community.

EXAMPLES FROM THE FIELDTools for determining essential personnel. As part of its

essential function staff recommendations, Purdue Universityoutlines a system of color-coding employee groups as a meansof providing simple, clear guidance to faculty, staff, andstudents regarding their responsibilities and course of action

44 HUMAN RESOURCES | H1N1 & Higher Ed: Lessons Learned

Purdue University

Essential and Non-essential Employee Groups

An Essential Function Staff Recommendation documenthas been drafted to provide simple, clear guidance tofaculty, staff, and students regarding theirresponsibilities and course of action in the event of apandemic or other crisis that requires severely limitedaccess to the university.

The following four groups are proposed as a means ofidentifying each employee’s responsibility level during anemergency:

Red Group Employees needed to maintainessential critical infrastructure andpublic safety functions during a campusemergency. These individuals willnormally be required to be on campusdaily and may need to stay on campusfor extended periods.

Orange Group Individuals needed to maintain criticalfunctions whose daily presence oncampus would not be required but whocan perform their roles on a periodic orrepetitive basis each week.

Blue Group Many of these staff can accomplishtheir function from remote locations orwith brief, occasional visits to campus.

Green Group All employees not already listed. Whiletheir functions are important to the university during normal operations,they are not deemed critical during an

emergency.

TOOLS FROM THE FIELD

in the event of a pandemic or other crisis that requiresseverely limited access to the university.

H1N1 Essential Personnel Recommendation (IN)

Reinforcing the need for redundancy. Planners at theUniversity of Minnesota used a high-absenteeism scenarioas part of a tabletop exercise to (1) illustrate how a pandemiccould affect members of the university’s pandemic influenzaresponse team and (2) creatively build support for identifyingthree backup employees for each response position. Theactivity leveraged the element of surprise inherent in apandemic. Based on random markers, members learnedwhether they were deceased, were sick, had sick familymembers, or were not affected.

The exercise illustrated that:

• Most of the population would survive a pandemic

• Most healthcare would be provided in the home by familymembers

• The impact across the response team could be spotty andunpredictable

• Assigning three trained backups for each response lead was a must

Workforce Absenteeism Exercise (MN)

Planning for HR in a pandemic requires harmonizing legalresponsibilities, myriad contractual requirements,epidemiologic information, cultural expectations, anduniversity operations. The H1N1 pandemic provided a greatdeal of insight into what issues need further exploration atthe university level, but more work remains.

For details please see the Higher Education section of

CIDRAP’s Promising Practices site.Purdue University

H1N1 Essential Personnel Recommendation (IN)

University of IllinoisHR Guidance Development (IL)

University of Minnesota Facemask and N95 Respirator Recommendations(MN)

State of Emergency Policy (MN)

Workforce Absenteeism Exercise (MN)��

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Human Resources Practices Online

H1N1 & Higher Ed: Lessons Learned | HUMAN RESOURCES 45

University of Minnesota

Workforce Reduction ActivityThis exercise is a vivid way to illustrate the impact on a workforce from absenteeism caused by a severe pandemic. During the activity, participants are randomlyassigned markers to represent the following:

Percent Employee is . . . of population

Not affected 35%

Caring for 1 ill family member 20%

Caring for 2-3 ill family members 13%

Sick 30%

Deceased 2%

TOOLS FROM THE FIELD

Human resource professionals

worked to determine how to ensure

sick employees stayed away from the

workplace, how to protect healthy

employees until a vaccine became

available, and how to staff for swings

in demand for certain services.

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Lessons Learned Recap

• Clear and timely information was needed for HR professionals, department heads, supervisors, and employees toeffectively implement public health recommendations in the workplace.

• Pandemic response efforts highlighted the importance of COOP planning on campuses, including the designationof essential personnel.

Actions and Challenges Ahead Include• Designating essential personnel across the entire campus (a challenge cited by some universities).

• Additional planning related to compensation policies during a more severe pandemic, when social distancingmeasures are implemented (a need noted by some universities).

THE POST-H1N1 LANDSCAPE: HUMAN RESOURCES

46 HUMAN RESOURCES | H1N1 & Higher Ed: Lessons Learned

s university planners responded tothe challenge posed by the thousandsof students on their campuses at riskof H1N1 infection, many discovereda plentiful resource: studentsthemselves. With a slight shift ofperspective, universities found thatstudents who might pass germs couldalso spread hygiene messages.

Likewise, students who need vaccine might be able toadminister vaccine, and students in need of housing couldhelp plan for housing the ill.

By viewing students as stakeholders who have (1) built-inexpertise on students’ needs and interests, (2) knowledge, and(3) skills, or the ability to gain them, many universities in theBig 10+2 enhanced their H1N1 response. Students filled avariety of roles, from frontline educators to vaccinators andinitial triage support staff.

This experience serves as a reminder that including vulnerablestakeholders in emergency planning and response can lead tounexpected, more effective approaches, as well as increasingtrust between the university and the campus community. This chapter addresses student engagement experiences.Examples from the field follow each lesson learned.

Lessons learned during the pandemic response emphasizedthe following:

• Student involvement can reduce demand for healthcareservices and expand healthcare surge capacity.

• Students have credibility with their peers, which givesthem a powerful voice and role in health education.

• Including students in planning improves support for the plans.

• Students and universities benefit from studentparticipation in emergency response.

LESSON: Students expand healthcare surge capacityAs universities grappled with preventing the spread of H1N1

and treating ill students,they also faced thechallenges of finding extrastaff, hours, or funds withinhealthcare systems thatroutinely operate at or nearhuman and fiscal capacity.Students were valuableresources in increasing healthcare surge capacity for severalBig 10+2 universities. Students who already had specializedskills were directed to tasks such as administering flu vaccinesor planning and staffing mass clinics. Students who werewilling to help but lacked some skills were either given just-in-time training and education or offered opportunities thatrequired dedication rather than skill.

Some of the benefits of enlisting student assistance wereeasily measured: Pennsylvania State University had 15 to20 upper-level nursing students serving as vaccinators at eachof the campus clinics. They delivered approximately 4,500doses of vaccine and allowed the university to save money onovertime wages and temporary part-time nurse salaries. Anunpaid internship program resulted in an additional 36hours a week of staff time at a campus health servicethroughout most of the pandemic.

Other activities are harder to measure but were described asuseful or successful. Several universities identified studentswho were already working with other students—such as RAs,peer health educators, and student Red Cross volunteers—and armed them with the training and materials they neededto provide H1N1 education.

EXAMPLES FROM THE FIELDStudents work vaccine clinics. Peer health educators

(PHEs) at the University of Chicago assisted with H1N1vaccination clinics, providing hygiene and self-careeducation. The PHEs, who were typically studying publichealth, medicine, or science, were tested to ensure they wereproviding correct information. This approach alloweduniversity health services to greatly expand its educationaloutreach without further stretching clinic staff. Students Serve as Peer Educators (IL)

H1N1 & Higher Ed: Lessons Learned | STUDENT ENGAGEMENT 47

CHAPTER 8

Student Engagement

How did students improve H1N1 response on campus?

Students are

‘a tremendous

asset’

KEY TAKEAWAY

Empowering health educators for H1N1. Alongstanding health advocate program at the University ofMinnesota features students who receive training and thenserve as health resources in residence halls, Greek houses, orother student housing. Health advocates can distribute first-aid and reproductive health items and work on healthpromotion activities such as starting a hall fitness club.

With the advent of H1N1 on campuses, health advocates’roles expanded. They received training on H1N1 and campusresponse procedures and how to detect and report flu-likeillness. They were fitted with N95 respirators. They receivedhand-washing reminders to hang in bathrooms and surgicalmasks to distribute. They learned to identify when studentsshould stay in their rooms and rest and when to send themto health services. They also had access to a 24-hour nurseline to assist with decision-making.

Student Health Advocates Also Address H1N1 (MN)

LESSON: Students are trusted messengersfor studentsRisk communicators know that a message’s acceptabilitydepends greatly on who delivers it. Universities harnessed thepower of peer pressure by enlisting students to educate otherstudents about the importance of good hygiene, flu vaccine,and self-care. Students climbed onto buses and into costumesand in myriad ways delivered key information to their peers.While even students concede it is difficult to convince youngadults they aren’t invincible, they cited successes.

Students suggested approaches to reach their peers that non-students might not have considered. For example, studentsrecommended creating a costume character, making andsharing stickers, and targeting vaccine education toparticipants preparing for a large student dance marathon.

EXAMPLES FROM THE FIELDGetting on the bus. Members of the Purdue University

chapter of the American Red Cross, in addition to otherstudent volunteers, rode CityBus vehicles on routes servingthe campus in the fall of 2009. They succeeded in distributingeducation materials and hand sanitizer to more than 5,000students in 2 days.

American Red Cross Student Chapter H1N1 Project (IN)

Creating internships. Pennsylvania State Universityhas a school of nursing as well as health policyadministration, which became a resource for the UniversityHealth Services (UHS). The infection control nurse managerat UHS created an infection control internship program tobolster staff levels for outreach and flu clinics. She found fourundergraduate interns whose work included a heavyemphasis on education and outreach, particularly aroundincreasing vaccination. Together the interns worked about 36hours a week for much of the pandemic, with a focus onhealth education and planning vaccine clinics. In addition toteaching their peers, the interns said they found it easy to tap their peers as volunteers, for example, by asking forvolunteers during nursing classes.

Infection Control Internships Help Students,

Health Services (PA)

LESSON: Including students in planning improves supportHousing ill students has been a complicated problem sincethe early days of pandemic planning. Universities havestruggled with housing ill students on campus as well asplacing students who can’t get home in a more severepandemic if the campus closes. Students proved to be anexpert resource and an important stakeholder group.

EXAMPLES FROM THE FIELDStudents change isolation approach. The University of

Chicago was one of the first nationally to have an H1N1case. Forced to make decisions without much data, plannerssought to simplify isolating the ill. Planners asked studentsnot affected by the virus to relocate so students withconfirmed or suspected cases could move into housing withprivate baths. Students rejected the idea of moving toenhance isolation of sick peers.

Planners revisited housing options during the summersession, but this time they included students who wereidentified by student government and various housingcouncils. Ultimately, ill students were housed in place andtheir healthy roommates were given the option to move out.None of the roommates chose to move.

Students Developed Housing Plan in Response to H1N1 (IL)

They actively sought ways tohelp us. It was amazing.

Lisa James, RN, MSNInterim Administrative Director, Student Health Service

University of Iowa

NOTES FROM THE FIELD

Students will listen to other students.

Shelley Haffner, Infection Control Nurse Manager, University Health Service

Pennsylvania State University

NOTES FROM THE FIELD

48 STUDENT ENGAGEMENT | H1N1 & Higher Ed: Lessons Learned

International students, planners reach out tocommunity for emergency housing. In the early years ofpandemic preparing, Michigan State University plannerswere concerned about the possible impact of a severepandemic, particularly on their thousands of internationalstudents from more than 130 countries. The Office forInternational Student Services (OISS) on campus became avaluable planning partner, serving as a link to theinternational students and working closely with students,international student clubs, and community groups. OISSstaff initially reached out to community clergy and churchmembers to learn whether families would be willing to hostinternational students who needed emergency homes.

Students also reached out to the community to help plan fortheir own needs. Although the planning effort was informaland the issue didn’t arise with H1N1, in a more severe event,MSU might formalize this housing option.

International Students Participate in Planning Alternative

Housing (MI)

LESSON: Students, universities benefit fromstudent engagementThe experience of Big 10+2 universities demonstrated thatengaging students in planning for and responding to aninfluenza pandemic strengthens response on campus. Studentinvolvement can spell an increase in surge capacity, peer-to-peer health education outside clinical settings, greater supportfor plans, and more flexibility. For example, student nurseswho were qualified to administer vaccines sometimes hadbroader availability than contract nurses and worked at massvaccination clinics on short notice on evenings and weekends,as vaccine arrived. Universities also benefited from recognizingthat students have time, energy, and insights to contribute.H1N1 response shows that universities stand to benefit greatlyfrom continuing to expand the network of students involved.

For students, being involved in H1N1 response meant a lotof things. Some received college credit. Many receivedvaluable training and résumé-building opportunities. Someexpressed delight in knowing their opinions were valued,such as the student who said, “It was kind of funny havingadults asking nursing students about H1N1. Even in class,instructors were asking me and the other two nursingstudents questions about H1N1.”

Another student said H1N1 response was life-changing. Oneundergraduate student at Pennsylvania State Universitywas contemplating her career options in health policy whenshe received an internship in infection control. As a result ofthat internship, she decided to apply for an acceleratednursing program. “I got more out of it than I could havedreamed—a complete career choice came out of it,” she said.“It was the most beneficial experience of my college career.”

Students proved a tremendous resource in responding tothe H1N1 pandemic on many college campuses, both asvolunteers and, in some cases, as paid employees. Theyhelped to teach their peers about influenza and hygiene,hopping buses, handing out hand sanitizer, and answeringquestions right in residence halls. Students helped reducethe health services staffing pinch on some campuses byplanning and/or assisting in vaccination clinics. Studentswere also important stakeholders in planning. Giving thema voice in the decision-making process, such as for housingill students, improved support for plans. These variedexperiences of student engagement offer useful examplesfor the future.

University of Iowa

Example: RAs Handle Phone CallsFrom Sick Students

The University of Iowa developed protocols to help RAsrespond to ill students in residence halls. Here is anabbreviated protocol for RAs when sick students call thefront desk:

If a student or parent calls about an ill student, please respond accordingly:

� Ask if the student is in crisis/needs immediateassistance. Example: is too weak to walk to bathroom.

� If YES:

• Inform the caller you will call an ambulance.

• Call 911 and request an ambulance.

• Call Professional staff on duty & RA on duty.

� If NO:

• Get a phone number, name, and room number of thestudent and inform the caller that a residence lifestaff member will be in contact within the hour.

• Contact the Hall Coordinator on duty between 8 AMand 5 PM Monday - Friday. Relay information.

• Contact the RA on duty between 5 PM and 8 AM andweekends/university holidays. Relay information.

� If they need a meal pack:

• If they want it for the next calendar day—they shouldfill out an online request.

• If they woke up ill and want it TODAY—they can callthe Burge or Hillcrest Marketplace.

TOOLS FROM THE FIELD

H1N1 & Higher Ed: Lessons Learned | STUDENT ENGAGEMENT 49

Pennsylvania State University

Example: It’s a (Flu) Bug’s Life

Lauren Zaun was a senior nursing major when shereceived an internship in infection control. She spenthours dressed as Flu Bug, handing out H1N1 fliers. Somestudents wanted photos with the bug. Others took fliersout of pity. Here’s her story:

One day the infectioncontrol interns andsome health servicestaff members werebrainstorming ideasabout how to tellstudents to clean theirhands and stay homewhen sick. Zaun hadjust read aboutstudents gettingattention for being incostume, “So I waslike, ‘Why don’t wehave a flu bug costume?’” A staff member made thecostume, and Zaun found herself attending homecomingdressed as a giant virus. “I was dancing around, gettinghugs from little kids, and it was fun,” she said.

Although Zaun also participated in a number of clinic-planning and student-monitoring activities, one of themost memorable parts of her senior year was time spentas Flu Bug. “It got a lot of attention,” she said. “When wewere handing out fliers, people would say things like ‘Oh,I have to take one from the bug.’”

“College students are a hard population. They were upthere in risk for H1N1, so it was extremely important that[they] knew what was going on. To try to get them to careabout flu was a big process,” Zaun said.

The interns’ efforts paid off. Students who met Flu Bugsometimes phoned friends to come have photos takenwith the bug. Soon after Flu Bug made its debut, vaccineclinic staffers asked students how they heard about theclinics and learned that Flu Bug had sent them. Internshanded out flu-related stickers and later spotted studentswearing them on campus.

“It was interesting,” Zaun said. “I never got the flu, but Ididn’t mind being the flu.”

TOOLS FROM THE FIELD

Four infection control interns atPennsylvania State Universitydonned a “flu bug” costume topromote H1N1 prevention.

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For details please see the Higher Education section of

CIDRAP’s Promising Practices site.Michigan State University

International Students Participate in PlanningAlternative Housing (MI)

Pennsylvania State UniversityInfection Control Internships Help Students, HealthServices (PA)

Purdue University (and the Purdue Chapter of theAmerican Red Cross)

American Red Cross Student Chapter H1N1 Project(IN)

University of ChicagoStudents Developed Housing Plan in Responseto H1N1 (IL)

Students Serve as Peer Educators (IL)

University of Iowa Health Sciences Students Administer Vaccine onCampus (IA)

Resident Assistant Checklist for Assessing Students(IA)

University of MinnesotaStudent Health Advocates Also Address H1N1 (MN)�

��

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Student Engagement Practices Online

50 STUDENT ENGAGEMENT | H1N1 & Higher Ed: Lessons Learned

Student involvement can spell an

increase in surge capacity, peer-to-peer

health education outside clinical

settings, greater support for plans, and

more flexibility.

Lessons Learned Recap

• Student involvement can reduce demand for healthcare services and expand healthcare surge capacity.

• Students have credibility with their peers, which gives them a powerful voice and role in health education.

• Including students in planning improves support for the plans.

• Students and universities benefit from student participation in emergency response.

Actions and Challenges Ahead Include• Formalizing roles for students in pandemic influenza planning and response.

• Looking to underused and less formal resources for planning and outreach activities, such as international student groups or churches that have high student membership.

THE POST-H1N1 LANDSCAPE: STUDENT ENGAGEMENT

H1N1 & Higher Ed: Lessons Learned | STUDENT ENGAGEMENT 51

52 H1N1 & Higher Ed: Lessons Learned

o get from one side of the 2009H1N1 influenza pandemic to theother, Big 10+2 universities relied onstrong alliances with public healthpartners at all levels of government.For large campuses, which operatelike cities, pandemic influenzaplanning and response demanded asignificant level of community

organizing. In addition to residence halls and large worksites,many universities include charter schools, day care centers,law enforcement agencies, first responder systems, hospitals,and community clinics.

Operating within a culture of self-sufficiency and outside ofthe traditional public health structure, university officialsdaily meet the public health needs of all who live, work, andvisit on campus. During public health emergencies, closecoordination with public health authorities is essential formany reasons, including (1) to ensure access to neededinformation and materials, (2) to provide consistentresponse actions and messaging, and (3) to capitalize on thevarying resources and expertise among all parties.

This chapter examines the need for strong collaborations,what worked well, and aspects that may need improvement.Examples from the field follow lessons learned.

Lessons learned during the pandemic response:

• CDC guidelines for institutions of higher education arean important resource for colleges and universities.

• Relationships with city, county, and state healthdepartments, often established through years of jointplanning, paid huge dividends.

LESSON: Federal guidelines for higher education are importantUniversity responders noted the importance of CDCguidelines in general throughout the pandemic, and inparticular emphasized the need for guidance documentsaddressed to institutions of higher education. Althoughrevised over time, initial recommendations, particularly those

on creating isolation space inresidence halls, wereproblematic for larger schoolswith limited available space.Big 10+2 universities haveoffered to work with the CDCin the future to ensure thatfederal guidelines areappropriate for all types ofinstitutions. The need tohighlight individual

recommendations in stand-alone, targeted communicationswas also identified. A communication system needs to beestablished between higher education and CDC personnel sothat specific challenging issues can be addressed as neededduring a pandemic or other public health emergency. Anexample from H1N1 response is to have therecommendation to suspend use of doctors’ notes forexcused classroom absences in a format addressedspecifically to faculty. Another example is to have therecommendation for students with flu-like illness to recoverat home targeted to community clinicians.

LESSON: Relationships with state and localhealth departments paid huge dividendsBig 10+2 universities reported that partnerships with publichealth authorities during the 2009 H1N1 influenzapandemic were indispensable, mutually beneficial, and oftena source of professional pride. They used the words“extraordinary,” “excellent,” and “positive” to describe thesesuccessful collaborations. Many universities have long-established relationships with their local health departmentsfrom participating in extensive efforts to bolster public healthpreparedness and response capabilities since 2001.

Public health systems vary in each state, as do universitysystems, so no two collaborations looked the same. Someuniversities include public health officials on planning andresponse teams; many reported daily phone and e-mailcommunications with public health partners. Jointdebriefings, shared situation reports, and conference callswere all used to ensure continued coordination throughoutthe extended response timeframe.

H1N1 & Higher Ed: Lessons Learned | COLLABORATIONS 53

CHAPTER 9

Collaborations With Public HealthHow did collaborations between universities and their public health partners enhance response?

Established

partnerships

enhance

response

KEY TAKEAWAY

Although established relationships were noted across theboard with local health departments, not all universities havea direct relationship with their state health department.Given the authority and decision-making happening at thestate level, some universities expressed a need to establish orenhance those relationships in the future.

Although close collaboration was needed throughout thepandemic on myriad topics and issues, some areas wereparticularly important:

• Ensuring a coordinated approach: Universities and publichealth departments worked together to sync messaging,trouble-shoot problems, share information necessary toanswer questions, and calibrate their respective responses.Early in the pandemic, uncertainties about the future requireduniversities to develop response options for a multitude ofscenarios. Just-in-time decision-making was required on awide ranging list of issues, from study-abroad programs inMexico, handshaking during graduation ceremonies, and thestatus of summer camps to policies and procedures inresidence halls. All of this was occurring during a time ofinformation overload. With constant information updatesfrom federal, state, and local sources, responders reportedspending several hours each day trying to stay current. Inaddition, media interest in H1N1 was high, with particularfocus on the impact and response on college campuses.

To harmonize messages, universities worked to clearinformation and practices with public health partners inadvance of dissemination. One university responderdescribed it as, “We wanted to make sure we were all singingoff the same sheet of music.”

• Vaccine distribution. Vaccine distribution was the biggestarea of conflict but also provided the best examples ofcollaboration between universities and the public healthsystem. On the conflict side, the lack of information andunpredictability of vaccine supplies were huge sources offrustration for college campuses, as it was for all healthcareand public health partners. A lack of transparency andshared understanding about the distribution process at alllevels was a challenge that should be addressed before thenext pandemic. On the other hand, universities and publichealth agencies partnered extremely well to share vaccineas needed, and to share the resources needed to distributeit. Collaborative planning efforts, strategies for deliveringvaccines, and the ability and willingness to work togetherpaid off in the immunization of thousands of students,faculty, staff, dependents, and, in many cases, communitymembers.

• Government stockpiles. Some universities cited the needfor a better understanding of access to government-held or-funded stockpiles of medication, PPE, and other supplies.

EXAMPLES FROM THE FIELDSpelling out the terms of working together. Purdue

University and the Tippecanoe County Health Departmentsigned a memorandum of understanding (MOU) thatdetailed roles and responsibilities if the county needed to usePurdue facilities to distribute items such as vaccines ormedications. According to the MOU, the county healthdepartment has primary responsibility to activate plans tomitigate public health emergencies (including pandemics)and to coordinate emergency functions. Purdue, it states, hasfacilities “that would be of particular assistance to the HealthDepartment for purposes of providing vaccinations,distributing prophylactic medications or other supplies.”

Memorandum of Understanding for Prophylaxis During Public

Health Emergencies (IN)

Relying on the influence of a state epidemiologist.During the pandemic, the University of Minnesota(U of M) joined periodic conference calls convened by theMinnesota Department of Health to exchange informationwith higher education institutions statewide. The stateepidemiologist provided H1N1 updates, answered questions,and requested reports from institutions on their status andchallenges. On one call, a college campus reported a concernthat athletes were attending practices and games despitehaving flu-like symptoms. Based on that report, theepidemiologist rapidly created and distributed an open letterto athletic directors and coaches that reinforced the need for

This response required anunprecedented level of communityorganizing over an extendedperiod of time. We need to makesure that our government partnersunderstand that we are not justschools; we are not justworkplaces; we act like cities. On adaily basis, that is how we operate.We are really responding at acommunity level in the face of apandemic or other public healthemergency.”

Jill DeBoer, MPHDirector, Academic Health Center, Office of Emergency

Response, University of Minnesota

NOTES FROM THE FIELD

54 COLLABORATIONS | H1N1 & Higher Ed: Lessons Learned

prevention measures in the sports setting. Although theconcern did not originate there, the U of M capitalized on thetargeted letter to reinforce existing messages and practices.The use of targeted messages from experts should beincorporated into future plans.

Open Letter to Athletic Directors and Coaches (MN)

Routine operations of a university in many respectsresemble routine operations of a community. When facedwith challenges such as an influenza pandemic,universities can and should rely heavily on outsiderelationships with public health partners at all levels ofgovernment. Sharing and leveraging resources throughpartnerships is the most effective way to promote seamlesspublic health response in an emergency.

For details please see the Higher Education section of

CIDRAP’s Promising Practices site.Minnesota Department of Health

Open Letter to Athletic Directors and Coaches (MN)

Purdue University and the Tippecanoe County Health Department

Memorandum of Understanding for ProphylaxisDuring Public Health Emergencies (IN)

��

Collaboration Practices Online

Lessons Learned Recap

• CDC guidelines for institutions of higher education are an important resource for colleges and universities.

• Relationships with city, county, and state health departments, often established through years of joint planning,paid huge dividends.

Actions and Challenges Ahead Include• Maintaining effective partnerships with local public health departments.

• Developing or enhancing direct relationships with state health departments as needed.

• Reviewing federal guidelines for higher education to ensure appropriateness for all types of institutions.

• Considering the creation of targeted communications on individual guidelines where there may be confusion or a need for reinforcement from a government authority.

• Seeking greater transparency is needed regarding vaccine distribution procedures to improve consistency andshared understanding among response partners.

• Gaining greater clarity in some jurisdictions (where warranted) regarding university access to government-held orgovernment-funded stockpiles.

THE POST-H1N1 LANDSCAPE: COLLABORATIONS WITH PUBLIC HEALTH

H1N1 & Higher Ed: Lessons Learned | COLLABORATIONS 55

56 H1N1 & Higher Ed: Lessons Learned

The picture that emerges from theBig 10+2 universities shows that the2009 H1N1 influenza pandemicrequired a highly coordinatedresponse over an extended period.Multidisciplinary teams workedefficiently during periods ofuncertainty, high stress, andchanging information and

recommendations. Students clearly emerged as keystakeholders who contributed to creative and effective

solutions in areas such as educating peers, administeringvaccine, and revamping plans about where to house sickstudents who could not leave campus.

In sharing the lessons they learned and the challenges thatremain, Big 10+2 universities have documented a baseline ofexperience with an influenza pandemic in the 21st century.The table on the next two following pages summarizes thelessons learned and future challenges in the key topic areasaddressed in this report.

H1N1 & Higher Ed: Lessons Learned | CONCLUSION 57

ConclusionSharing lessons and ongoing challenges, Big 10+2 universities have documented a baseline of experience with a pandemic in the 21st century.

Multidisciplinary teams worked efficiently

during periods of uncertainty, high stress, and

changing information and recommendations.

Students clearly emerged as key stakeholders

who contributed to creative and effective

solutions.

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Incident Management

Residence Halls

Health Services Communications

• Pre-pandemic planning effortswere invaluable to establish rela-tionships and determine roles andresources. Written plans, particu-larly specific response actionsbased upon external triggers,often did not match this pan-demic.

• The use of multi-disciplinary response teams was reported asan overwhelming success.

• Integrating pandemic prepared-ness and response with broaderemergency operations systems,particularly determining clearlines of responsibility and author-ity, was important.

• Universities developed creativesolutions to the challenge of co-ordination and communicationamong response personnel overan extended response period.

• Specific procedures for summercamps hosted on campus are animportant component of pan-demic influenza response plans.

• Designating isolation housing forsymptomatic students or relocat-ing students can be challengingdue to housing logistics and student preferences.

• Sending symptomatic studentshome for a specified period canbe successful.

• If multiple campus supports arein place, students who cannot orchoose not to go home can successfully self-isolate in theirresidence hall rooms.

• Student leaders did and can con-tinue to play an important role.

• College-aged students wereamong the groups of peoplemost at risk of developing com-plications from H1N1 infection.Universities became importantsites for care, with campushealth services playing a keyrole.

• Streamlining operations was asuccessful approach to maintainquality and effectiveness withinthe health service.

• Online and phone-based triagesystems were used effectively toprovide care information and re-ferrals to patients.

• Prescribing self-isolation andhome care can be a successfulstrategy if adequate support sys-tems are put in place.

• Campus partners were availableto provide additional staff sup-port within the health service.

• Student leaders played an impor-tant role in providing informa-tion and care.

• Due to the rapidly changing, andsometimes conflicting, informationfrom multiple sources, universityresponders had to proactively co-ordinate and centralize communi-cations.

• Universities relied heavily on on-line and e-mail communications as timely forums for informationexchange.

• Effective communication with college students meant a heavyemphasis on creativity.

• Maintaining and supportingcampus response teams, in what-ever form works best for each in-stitution, to ensure a continuedstate of readiness.

• Documenting and sharing successes related to coordinationand communication among response team members.

• Revising response plans to remove triggers tied to WHOphases and US stages and/orseverity index.

• Expanding pandemic influenzaresponse plans to include less severe scenarios based uponwhat worked and what did notwork in 2009 and 2010.

• Increasing communication be-tween universities and the CDCon the development of highereducation guidelines, particularlyrelated to residence hall recom-mendations.

• Possibly boosting the role publichealth partners play in educatingfamily clinicians about the importance of reinforcing self-isolation recommendations forsymptomatic students.

• Documenting and sharing healthservice successes.

• Ensuring adequate pandemic response supplies through stock-piling, which continues to be achallenge. In particular, havinggreater clarity about access tofederally available antivirals atthe campus level would be usefulfor many institutions.

• Encouraging additional federaldialogue on the use of PPE during a pandemic to ensureclear and consistent informationat the local level. Availability ofN95 respirators and fit-testing resources, including stockpilingconsiderations, was also cited asa challenge.

• Getting clarity about what someuniversities considered vaguefederal guidance about prescrib-ing antiviral medications. Guide-lines provided were cited bysome as too restrictive, and lackof clarity led to frustration.

• Sharing lessons learned aboutthe use of non-alcohol versus alcohol-based hand sanitizers, as well as the appropriate short-and long-term investments inthose products, would be beneficial.

• Having public health partnersplay a greater role in educatingfamily clinicians about the importance of reinforcing self-isolation recommendations.

• Documenting and sharing communication successes fromthis pandemic.

• Identifying additional creative waysto communicate with parents (aneed reported by some institu-tions).

• Expanding and leveraging publichealth partnerships to harmonizecommunications could further savetime and resources.

Actions &

ChallengesAhead

LessonsLearned

58 CONCLUSION | H1N1 & Higher Ed: Lessons Learned

Vaccine Distribution Teaching

HumanResources

StudentEngagement

Collaborations WithPublic Health

• Vaccine distribution to universi-ties was unpredictable, whichmade planning and implemen-tation of distribution efforts oncampus very challenging.

• Past seasonal influenza vacci-nation experiences and bioter-rorism response planning withpublic health partners provideduseful templates for H1N1 vaccine distribution.

• Due to the challenges of un-predictable vaccine availability,creative strategies were devel-oped rapidly using online orphone-based systems.

• Creative approaches were alsoused to meet significantstaffing needs.

• Pandemic influenza responseplans need specific proceduresto address the effects on study-abroad programs.

• Teaching policies and individ-ual faculty practices play an important role in supportingself-isolation strategies for students.

• Although distance learningtechniques were not required,hindrances to their successfulimplementation were high-lighted during pre-pandemicplanning.

• Clear and timely informationwas needed for human re-source professionals, depart-ment heads, supervisors, andemployees to effectively imple-ment public health recommen-dations in the workplace.

• Pandemic response effortshighlighted the importance of continuity of operationsplanning on campuses, including the designation ofessential personnel.

• Student involvement can re-duce demand for healthcareservices and expand healthcaresurge capacity.

• Students have credibility withtheir peers, which gives them apowerful voice and role inhealth education.

• Including students in planningimproves support for the plans.

• Students and universities bene-fit from student participationin emergency response.

• CDC guidelines for institutionsof higher education are an important resource for collegesand universities.

• Relationships with city, county,and state health departments,often established throughyears of joint planning, paidhuge dividends.

• Documenting and formalizingthe new and modified vaccinedistribution systems that wereused successfully in response toH1N1.

• Considering use of pre-distribu-tion education on LAIV andworking with public healthpartners to increase awarenessof LAIV in the community.

• Requesting that CDC considerthe creation of targeted com-munications to faculty on theneed to modify policies andpractices when self-isolationstrategies are used to addressinfectious disease outbreaks.

• Reviewing and further devel-oping (as needed) models foraddressing existing self-isola-tion policies and the role offaculty in providing informa-tion and support to students.

• Documenting procedures usedto make policy modifications,either formally or informally,so that those modifications canbe made rapidly in the future.

• Further developing distancelearning capabilities in someinstitutions, including teachingstrategies, faculty preparation,and information technology infrastructure.

• Designating essential person-nel across the entire campus (a challenge cited by some universities).

• Additional planning related tocompensation policies during amore severe pandemic, whensocial distancing measures areimplemented (a need noted bysome universities).

• Formalizing roles for studentsin pandemic influenza plan-ning and response.

• Looking to underused and lessformal resources for planningand outreach activities, such as international student groups or churches that havehigh student membership.

• Maintaining effective partner-ships with local public healthdepartments.

• Developing or enhancing directrelationships with state healthdepartments as needed.

• Reviewing federal guidelinesfor higher education to ensureappropriateness for all types of institutions.

• Considering the creation of targeted communications onindividual guidelines wherethere may be confusion or aneed for reinforcement from a government authority.

• Seeking greater transparency is needed regarding vaccinedistribution procedures to improve consistency andshared understanding amongresponse partners.

• Gaining greater clarity in somejurisdictions (where warranted)regarding university access togovernment-held or govern-ment-funded stockpiles.

H1N1 & Higher Ed: Lessons Learned | CONCLUSION 59

University of Minnesota project team

Center for Infectious Disease Research and Policy:Jill DeBoer (Principal Investigator), Amy LaFrance (ProjectDirector), Kathleen Kimball-Baker, Dave Bender, WynfredRussell, Natalie Vestin, Jim Wappes

Boynton Health Service: Ed Ehlinger

Academic Health Center Office of Emergency Response:Jill DeBoer, Elizabeth McClure, Joan Rambeck

School of Public Health: Paul Bernhardt

In addition, the project team would like to especiallythank the following people from Big 10+2 universitieswho gave their time and expertise to this project:

ELIZABETH ALEXANDER, MD, University Physician, Public Health Liaison (Michigan State University)

BOB ARMSTRONG, Director, EM and fire prevention (The Ohio State University)

CAROLINE BARNHILL, MPH, Director, Infectious Disease,Association of State and Territorial Health Officials (ASTHO)

LISA BARRIOS, DRPH, Centers for Disease Control and Prevention (CDC)

CELIA BERGMAN, Associate Dean of Students (University of Chicago)

MICHAEL BOHLIN, MD, County Health Officer, Tippecanoe County, IN

KRISTINE BORDENAVE, MD, Director, Student Care Center(University of Chicago)

PETER BRIGGS, Director, Office for International Students and Scholars (Michigan State University)

ANDY BURCHFIELD, Manager of the Office of EmergencyPreparedness (University of Michigan)

EMMA CASEY, University of Minnesota student

DIANA EBLING MD, Medical Director (Indiana University)

ED EHLINGER, MD, Director, Boynton Health Service (University of Minnesota)

KATHLEEN FITZGERALD, Assistant Director, University Housing,Office of Residence Life (University of Iowa)

CAROL GOSENHEIMER, Office of the Registrar (University of Wisconsin-Madison)

SHELLEY HAFFNER, Infection Control Nurse Manager, University Health Service (Pennsylvania State University)

KEVIN HELMKAMP, Offices of the Dean of Students (University of Wisconsin-Madison)

LISA JAMES, RN, MSN, Interim Administrative Director, Student Health Service (University of Iowa)

HUGH JESSOP, HSD, Executive Director and Chief Financial Officer,Indiana University Health Center (Indiana University)

DR. DAVID LAWRANCE, Medical Director at McKinley Health Center(University of Illinois)

STEVE LUND, Interim Human Resources Director (University of Wisconsin-Madison)

NANCY MACKLIN NP, Director of Nursing (Indiana University)

ANN MILLER, student (Pennsylvania State University)

DONALD MISCH, MD, Executive Director, Northwestern UniversityHealth Service (Northwestern University)

GLYNDA MOORER, MD, Director, Olin Health Center (Michigan State University)

JIM MORRISON, Occupational Health and Safety Officer(University of Wisconsin-Madison)

ROBERT PALINKAS, MD, Executive Director, McKinley HealthCenter (University of Illinois)

CRAIG ROBERTS, PA-C, MS, Epidemiology, Health Center Services(University of Wisconsin-Madison)

JIM ROONEY, EDD, Associate Director of Housing (University of Illinois)

JULIE SANEM, Adviser, Health Advocates Program, Boynton HealthServices (University of Minnesota)

CAPT. STEVEN ROGERS, campus police department (University of Wisconsin-Madison)

TODD SHORT, Director of Emergency Planning (University of Illinois)

CHERYLE SICKELS, RN, Primary Care Nurse Manager, UniversityHealth Services (University of Wisconsin-Madison)

DARLINDA SMITH-VAN BUREN, BSN, MPH, Nursing Administrator/Quality Improvement, Ombudsman/Accreditation, Olin HealthCenter (Michigan State University)

MARGARET SPEAR, MD, Director, University Health Service(Pennsylvania State University)

SARAH VAN ORMAN, MD, Executive Director, University HealthServices (University of Wisconsin-Madison)

MARSHA VANDERFORD, PHD, Centers for Disease Control andPrevention (CDC)

JAMES S. WESTMAN, PHD, Director, Student Health Center (Purdue University)

RON WRIGHT, DIRECTOR, Campus Emergency Preparedness &Planning (Purdue University)

LAUREN ZAUN, student (Pennsylvania State University)

ACKNOWLEDGMENTS

60 ACKNOWLEDGMENTS | H1N1 & Higher Ed: Lessons Learned

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BIG 10+2 UN IVERSIT I ES

Center for Infectious Disease Research & PolicyUniversity of MinnesotaAcademic Health Center420 Delaware St SEMMC 263Minneapolis, MN 55455www.cidrap.umn.edu